key: cord-0889924-pctp05hp
authors: Dexter, Franklin; Elhakim, Mohamed; Loftus, Randy W.; Seering, Melinda S.; Epstein, Richard H.
title: Strategies for daily operating room management of ambulatory surgery centers following resolution of the acute phase of the COVID-19 pandemic
date: 2020-04-29
journal: J Clin Anesth
DOI: 10.1016/j.jclinane.2020.109854
sha: 502f56b38b42bb84ac0c966f45d61ed1d82c7eb4
doc_id: 889924
cord_uid: pctp05hp

Abstract We performed a narrative review to explore the economics of daily operating room management decisions for ambulatory surgery centers following resolution of the acute phase of the Coronavirus Disease 2019 (COVID-19) pandemic. It is anticipated that there will be a substantive fraction of patients who will be contagious, but asymptomatic at the time of surgery. Use multimodal perioperative infection control practices (e.g., including patient decontamination) and monitor performance (e.g., S. aureus transmission from patient to the environment). The consequence of COVID-19 is that such processes are more important than ever to follow because infection affects not only patients but the surgery center staff and surgeons. Dedicate most operating rooms to procedures that are not airway aerosol producing and can be performed without general anesthesia. Increase throughput by performing nerve blocks before patients enter the operating rooms. Bypass the phase I post-anesthesia care unit whenever possible by appropriate choices of anesthetic approach and drugs. Plan long-duration workdays (e.g., 12-h). For cases where the surgical procedure does not cause aerosol production, but general anesthesia will be used, have initial (phase I) post-anesthesia recovery in the operating room where the surgery was done. Use anesthetic practices that achieve fast initial recovery of the brief ambulatory cases. When the surgical procedure causes aerosol production (e.g., bronchoscopy), conduct phase I recovery in the operating room and use multimodal environmental decontamination after each case. Use statistical methods to plan for the resulting long turnover times. Whenever possible, have the anesthesia and nursing teams stagger cases in more than one room so that they are doing one surgical case while the other room is being cleaned. In conclusion, this review shows that COVID-19 will markedly affect daily ambulatory workflow for patients undergoing general anesthesia, with potentially substantial economic impact for some surgical specialties.

We recently published a narrative review of infection control and operating room management for the care of patients undergoing surgery during the Coronavirus Disease 2019 crisis and who are not thought to have COVID-19 [1] . In the current article, we consider these topics for the period when surgery transitions from urgent to essential procedures and, progressively, as queues resolve, to elective surgery [2].

We limit consideration to ambulatory surgery, expecting that for a considerable time following the peak of SARS-CoV-2 infection, hospital beds often will be occupied with COVID-19 patients [3, 4] . The scheduling of surgery requiring inpatient admission will need to consider the constraint of limited intensive care unit and ward beds and the risk to such patients of nosocomial COVID-19 infection [5, 6] . There also will be considerations related potentially to the exclusion of visitors, unreliable availability of blood products, and a reduction in the healthcare workforce due to the consequences of the pandemic. However, ambulatory surgery accounts for 74.7% of surgical cases performed on regular workdays (i.e., non-urgent) [7, 8] . Essential and high-priority elective surgery that can expand earliest comprise procedures that can be performed safely in free-standing buildings, whether in hospital outpatient departments or at facilities unaffiliated with hospitals [9] . Although we refer to ambulatory "surgery," our intention is for the principles to apply fully to all procedures, whether or not an anesthesia provider is 

We assume that RT-PCR nasopharyngeal testing of all ambulatory surgery patients would not be combined with screening computerized tomography of the lung [11, 12] . There are patients infected with SARS-CoV-2 and presymptomatic or asymptomatic [13, 14, 15, 16, 17, 18, 19] .

A presymptomatic patient has virus present but is not yet manifesting any signs or symptoms of COVID-19. In the asymptomatic patient, radiographic changes (in the lung) are present, but the patient lacks any symptoms or has symptoms attributed to a different process (e.g., occasional cough in a patient with thoracic disease) [15, 16, 17, 18, 19] . Recognizing this potential hazard, the "American Association of Nurse Anesthetists, American Society of Anesthesiologists, Anesthesia Patient Safety Foundation, and American Academy of Anesthesiologist Assistants recommend as optimal practice that all anesthesia professionals should utilize personal protective equipment appropriate for aerosol-generating procedures for all patients when working near the airway" [20, 21] . We presume that all operating room staff (i.e., anesthesia providers, surgeons, and nurses) would be using some version of droplet precautions for all such patients [20, 21] . Other authors have discussed the implementation of barrier protection strategies, such as the use of traditional surgical mask and face shield, well fit N95 mask and face shield, etc. For our purposes of considering the economics of ambulatory surgery in the COVID era, we correspondingly partition ambulatory surgery into three categories: (section #3) no aerosol production by both the surgical procedure and the anesthetic, (#4) aerosol production by tracheal intubation and extubation, and (#5) aerosol production by the surgical procedure and general anesthetic.

There not only are patients infected with SARS-CoV-2 who are presymptomatic but also asymptomatic patients with radiological changes pathognomonic for COVID-19 [13, 14, 15, 16, 17, 18, 19] . Therefore, we expect that all patients undergoing anesthesia will have RT-PCR testing the day before surgery. Early in the disease, viral load is predominantly that J o u r n a l P r e -p r o o f JCA_2020_582R1, Page 6 of the upper airway (nasopharynx, oropharynx) [22, 23] . RT-PCR testing of the oropharynx (subsequently referred to as "COVID-19 testing") has high sensitivity [22, 23] . The negative predictive value probably is effectively 99.9%, and patients would be receiving topical viral decolonization preoperatively (see section 3). Therefore, we expect limited economic effects of COVID-19 from presymptomatic and asymptomatic patients not undergoing general anesthesia. However, during progression of the disease, there is a substantial false negative rate of oropharyngeal testing [24, 25, 26, 27] . Bronchoalveolar lavage specimens have detectable SARS-CoV-2 for more samples (93%) than sputum (72%), and much more than oropharyngeal swabs (32%) [28] . Consequently, as we address in sections 4 and 5, we expect large economic effects of COVID-19 from patients receiving general anesthesia.

This section applies to patients (a) undergoing procedures without airway aerosol production (e.g., excluding interventional pulmonary and upper gastrointestinal endoscopy) [29, 30, 31] and (b) receiving local anesthesia, monitored anesthesia care, and/or regional anesthesia including peripheral and spinal blocks with moderate sedation. Consequently, there would not be a need for airborne precautions [31] . Restricting many operating rooms from aerosol producing surgical procedures and general anesthesia would be practical because ambulatory surgery visits in the USA in 2006 were performed without general anesthesia for 69% of visits [32] . Anesthetics performed without general anesthesia accounted for 72% (SE 2%) of the anesthesia minutes among ambulatory surgery procedures performed in the USA in 2010 with an anesthesiologist and/or nurse anesthetists [33] . These statistics are functional overestimates because some aerosol producing procedures (e.g., upper gastrointestinal endoscopy) [30] are coded as being monitored anesthesia care even though the patient is "deeply" sedated for at least a portion of the procedure. Nevertheless, the point is that more than half of ambulatory surgery is performed without general anesthesia. There also are many common interventional During anesthesia, bacterial and viral contamination of the anesthesia workspace routinely occurs, largely due to activities of the anesthesiologist and/or nurse anesthetist caring for the patient throughout the case [1, 37, 38, 39, 40] . Multiple steps can be followed to mitigate this risk, as follows. (a) Decolonize patients using preprocedural chlorhexidine wipes, two doses of nasal povidone-iodine [41] within 1 hour of incision, and chlorhexidine mouth rinse [42, 43, 44, 45, 46, 47] . In the unlikely event of an upper respiratory sample for COVID-19 being false negative among patients with presymptomatic disease, SARS-CoV-2 will have been inactivated [48] . (b) Designate and maintain clean and dirty areas [49] . (c) Place alcohol-based hand rubs on the intravenous pole to the left of the providerspatial orientation matters [50] .

(d) Place a wire basket lined with a zip closure plastic bag on the intravenous pole to the right of the provider, for deposit of contaminated instruments (e.g., laryngoscope blade and handle)

[49]. (e) Create a closed lumen intravenous system and use hub disinfection [51, 52] ; prevent bacterial infection and coronavirus viremia [53] . (f) Double glove before touching the patient's nose/mouth and remove the outer glove following contact (e.g., placement of a nasal cannula) [54, 55, 56] . (g) After patient positioning, wipe down equipment and high-touch surfaces with disinfection wipes that contain a quaternary ammonium compound and alcohol spinal blockade neither produces aerosol from the nose/throat nor uses general anesthesia, yet patient nasal decontamination reduces surgical site infections [46] . The consequence of COVID-19 is that they are more important than ever to follow, because infection affects not only the patients but the ambulatory surgery center staff and surgeons.

Procedures performed without general anesthesia can be facilitated to increase daily surgical caseload and therefore reduce surgical queues. Management strategies include case scheduling for surgeons to have days with only monitored anesthesia care or regional anesthesia [64] . Using block areas with registered nurses trained to assist with regional anesthesia reduces operating room time and increases throughput [65, 66, 67, 68, 69, 70, 71, 72] .

The use of peripheral regional anesthesia reduces how long patients stay in the phase I postanesthesia care unit [69, 73, 74 There may be constraints on performing ambulatory surgery due to inadequate supplies of personal protective equipment. Potentially, some anesthesia machines may be out of service awaiting terminal decontamination due to their use for COVID-19 patients who developed respiratory failure. However, sedation, peripheral nerve blocks, and spinal anesthetics can be performed safely, although not ideally, in the absence of an anesthesia machine. Regardless, essential surgery needs to be completed. To reduce the progressively growing surgical queues, shifts should be as long as reasonable (e.g., 12 hours) [1] . Considerable data show that with this approach, ambulatory surgery centers have underutilized capacity; extending working hours [24] , 29% (15/51) [25] , 41% (413/1014) [26] , and 63% (384/610) [27] ; pooled 48% (818/1710). The estimates are heterogeneous because upper airway involvement declines as the disease progresses [22, 23] . Bronchioalveolar lavage (93%) and sputum samples (72%) have lower false-negative rates than oropharyngeal samples (32%) [28] . Asymptomatic patients will cause environmental contamination not only during tracheal intubation [83] but after extubation. can survive for at least 3 days on a variety of materials commonly encountered in ORs (e.g., stainless steel, plastic) [85] . COVID-19 infectivity cannot be accounted for, population-wise, without including environmental contamination [86] . The necessary environmental cleaning [58, 59] applies to the area around the patient, including the phase I post-anesthesia care unit.

We do not think that ambulatory surgery centers will be able to sustain reporting and contact tracing for all providers and patients exposed to a nurse or anesthesia provider who develops symptom onset is 5 days [95% confidence interval 4 to 7] with 95 th percentile 12 days [9 to 18]) [87] . The economic implication is that patients should have their initial (phase I) post-anesthesia recovery in the operating room where they had surgery; by "initial" we mean the period of coughing, disorientation, and sometimes bronchospasm right after tracheal extubation [1] .

The cost of having patients undergoing phase I recovery in the operating room need not be as large as it may seem. Apropos this recommendation, there are very few phase I postanesthesia care units in Japan [88] . Even for long-duration cases, patients in Japanese 

For many otolaryngology, gastroenterology, general surgery, oral surgery, interventional pulmonary and thoracic surgery cases, etc., the changes described in the preceding two sections would be necessary. Additionally, there would be multimodal environmental decontamination after each case [1] . This process includes treating operating rooms using a source generating ultraviolet-C [98, 99] Statistical methods to help the ambulatory surgery center determine how many housekeepers are needed have been developed and validated [106, 107, 108, 109] . These methods are useful in part because they are non-intuitive. First, determine the times of the workday when there are the largest number of unusually long turnovers, using one-hour epochs [106] . Making graphs or tables of the counts by hour will be helpful because the workdays should be far longer than typical before COVID-19 for ambulatory surgery centers [36, 79] . This increase in the length of the workday will occur because long-shifts reduce the amount of personal protective equipment used and reduce patient queues for care [1] . The graphs and tables help managers determine the times when the largest numbers of housekeepers are needed [106] . Next, each increase in the number of housekeepers and/or turnover teams will be associated with less overall mean minutes that teams work later than planned [107, 109] and lesser probability of prolonged turnovers [107, 108] . However, the relationship is asymptotic such that each increase in the numbers of housekeepers or teams has progressively lesser benefit [107, 109] . A useful statistic to use for managerial decisions is the mean daily minutes when the number of simultaneous turnovers is exceeding the number of housekeepers or teams [107] .

The statistic is related directly to the minutes that teams will work later than planned [107] . The difference is taken in the statistic calculated with and without the addition of 1 more housekeeper or team [107] .

As we think will be apparent, the economic effect of COVID-19 on daily operating room management of ambulatory surgery centers after the acute crisis period likely will be for those J o u r n a l P r e -p r o o f JCA_2020_582R1, Page 13 operating rooms being used for surgery with aerosol production to have the sometimes frustratingly slow performance of hospitals' surgical suites. We think that a good analogy would be the management of cases on Saturdays. The reason is that among US surgical suites on Saturdays, anesthesia and nursing teams often can have each team working in 2 operating rooms, allowing cleaning and setup while they are caring for another patient [8] . We previously published a review article for making operating room management decisions to reduce the hours that staff work late for use by surgical suites with long (10 hour) workdays [110] . The methods apply directly. In the current paper, we do not repeat this extensive and fully covered topic [110] . Rather, we make three points useful as ambulatory surgery centers learn how to apply the science.

First, a common challenge in applying principles to achieve maximal operating room utilization balanced versus preventing the hours that teams work late ("over-utilized time") is that different operating room managers reasonably disagree about how much time is worth saving to warrant moving a case from one room to another (e.g., 15 minutes or 30 minutes) [111, 112] .

Such heterogeneity of perspective on decisions can be neglected because turnover times will be 45 minutes or longer for most cases.

Second, usually making decisions to reduce the hours that staff work late, while filling the operating rooms, depends on calculating the operating room allocations, meaning the hours into which cases are scheduled [110, 113, 114] . That characteristically would be done by the combination of service and day of the week [110, 113, 114] . This usually is important because there are substantial differences among combinations of service and day of the week [115] .

After the peak of the COVID-19 pandemic has subsided, at facilities with a nearly unlimited queue of patients for surgery and with staff working at most 12 hours daily, this mathematics can be skipped. These dual objectives will need to be met while relying on few historical data [116, 117, 118, 119, 120] for cases' operating room times by procedure because previously phase I post-anesthesia care was not in the operating rooms. Ambulatory surgery centers (i.e., J o u r n a l P r e -p r o o f JCA_2020_582R1, Page 14 facilities performing many brief cases) [36] should schedule cases into operating room hours selected by policy (e.g., 11 hours) calculated for the end of the day to finish reliably by 12-hours [121, 122] . Case scheduling would pack as much as possible into those hours while not causing over-utilized time [110, 112, 123] .

Third, decision-making to maximize productivity is both difficult and counter-intuitive because of the conditions that will apply for these operating rooms: long workdays, longduration cases (i.e., including phase I recovery in the room), and long turnover times [110] .

Physicians and non-physicians tend to make operating room management decisions based on rules of thumb. Such heuristics perform poorly, and people do not realize the extent to which their case scheduling decisions are suboptimal [108, 124, 125, 126, 127, 128] . The knowledge and problem-solving skills to make those decisions well are not learned on the job by experience [108, 124, 125, 126, 127, 128] , but rather by study (e.g., a formal course in operating room management) [129, 130, 131, 132, 133, 134] .

J o u r n a l P r e -p r o o f JCA_2020_582R1, Page 15

We performed a narrative review of studies to predict the future economic effect of COVID-19 on daily operating room management of ambulatory surgery centers after the acute crisis period ends in their region. The review suggests the following targeted strategies for facilities using RT-PCR COVID-19 screening preoperatively but not chest computerized tomography [11, 12, 15, 16, 17, 18, 19] :

 Use multimodal perioperative infection control practices (e.g., including patient decontamination) and monitor performance (e.g., S. aureus transmission from a patient to the environment as a marker of behavioral performance). For details, see References (1) and (40), and infographic checklist and videos prepared by the Anesthesia Patient Safety Foundation [135] .

 Dedicate most operating rooms daily to ambulatory procedures that are not airway aerosol producing and do not need general anesthesia [32, 33, 34, 35, 36] . Increase throughput of these cases by using block areas with registered nurses to assist in the performance of regional anesthesia [65, 66, 67, 68, 69, 70, 71, 72] . Bypass the phase I postanesthesia care unit by appropriate choices of anesthetic approach and drugs [73, 74, 75, 76, 77, 78] . Plan long-duration workdays (e.g., 12 hours) to reduce the impact of personnel exposed to asymptomatic patients with COVID-19, and to reduce the large queues of patients needing essential surgery [1, 136] .

 Until a low-risk cure or effective prevention for COVID-19 is discovered, or a safe and widely used vaccine is developed, surgical procedures that do not result in aerosol production, but for which general anesthesia is administered, should have phase I postanesthesia recovery in the operating room where the surgery was performed. Consider following anesthetic practices that achieve fast initial recovery [89, 92, 93, 94, 95, 96, 97] .  When the surgical procedure results in aerosol production (e.g., bronchoscopy), have phase I recovery in the operating room and use multimodal environmental decontamination after each case [1] . Use statistical methods to plan for the long resulting turnover times [106, 107, 108, 109] . Whenever possible, have the anesthesia and nursing teams work in more than one room so that they are doing one surgical case while the other room is being cleaned. When patients have phase I post-anesthesia care in the operating room, after general anesthesia or surgery with aerosol production, the anesthesia provider could staff the recovery.

That would be logical if they would not go right away to another room to start a case. If they would start another case in another room, the post-anesthesia care unit nurse could come to the room, as done for some regional anesthetics [64] . That would, however, increase exposure of more healthcare workers to each patient during the period of airborne precautions and consume more personal protective equipment [1] .

We have not addressed general anesthesia and/or airway aerosolizing surgical procedures among patients who had COVID-19 and subsequently had two negative tests (i.e., the current method to assess that an individual no longer is contagious). We are unaware of sufficient data J o u r n a l P r e -p r o o f 

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