On May 1, Governor Ralph Northam allowed Order of Public Health Emergency Two, which temporarily halted all elective procedures at Virginia hospitals, to expire. The Order was issued to conserve healthcare resources and supplies because Virginia was experiencing a rapid rise in cases of COVID-19. There were legitimate concerns that hospitals could be overwhelmed by a surge of patients.
The efforts of Virginia's communities and medical facilities to flatten the curve and reduce the rapid spread of COVID-19 had success, so hospitals have been able to preserve the stock of Personal Protective Equipment (PPE) and other supplies, and have not been overwhelmed with patients. So after extending the Order for one week past its original expiration date of April 23, the Governor allowed it to expire. With this expiration, hospitals like Augusta Health can resume elective procedures.
To successfully resume these procedures, Augusta Health has initiated a carefully thought-out plan developed by a Task Force, appointed by the Hospital Incident Command Center (HICS) that includes members from the medical staff, clinical leadership, administration and support service directors. The hospital-wide team is led by Shawn Craddock, DNP, RN, CNOR, NE-BC, Administrative Director of Surgical Services at Augusta Health, with support from Chief Medical Officer, William Doherty, MD, and Chief Nursing Officer, MSN, RN, NE-BC, and in collaboration with Augusta Health's physician partners.
Conditions and Considerations
Augusta Health will reopen its elective outpatient services such as imaging, diagnostic procedures and imaging and all non-emergency surgeries three phases, as proposed by HICS after careful study and reflection on the recommendations and guidance provided by the Centers for Medicare & Medicaid Services (CMS), the American Hospital Association (AHA), and other specialty agencies.
Reopening of these services is dependent on several factors: The prevalence of COVID-19 in the community and the hospital, the stock of PPE and other medical supplies, the availability of COVID-19 tests, and physicians and staff.
In order to protect patients and staff in the event of Covid-19 Surge, Augusta Health's Incident Command Center will monitor many internal indicators to assess and ensure its capacity to see patients in a safe environment. The Command Center will track the number of tests and the number of positive cases at Augusta Health and in the SAW community. They will also monitor the number of patients seen at the Augusta Health Assessment Center in Waynesboro, and the number of calls to the COVID Care Call Center.
These factors are all indicators used to assess prevalence of Covid-19 in the hospital. Should Covid-19 increase, the hospital will adjust the number and types of procedures to be performed.
Craddock says, "We need to continue to monitor the number of cases of COVID in our community and our hospital, and be able to flex back to COVID operations if a second wave or surge of COVID-19 occurs."
Keeping Patients Safe
"We've been very diligent and deliberate about developing a plan that will work to keep our patients and staff safe and healthy while providing the services that many people in our community need," says Craddock.
Performing surgery on COVID-19 patients requires extensive resources such as PPE and puts staff and other patients at risk, so pre-procedure COVID testing will be completed on patients scheduled for surgery and some other specific procedures. Patients requiring testing will be tested at the Waynesboro Assessment Center at least four days prior to surgery. If COVID-19 is identified in a patient scheduled for surgery, the procedure will be postponed until the patient is no longer positive. In an emergency, surgery will proceed without delay, but with additional safety resources.
"It's recommended that we have a 30-day supply of PPE on hand at all times, so we need to carefully monitor our levels of PPE, as well as other medical supplies," adds Craddock.
"In addition to monitoring the availability of PPE and supplies, we'll monitor the availability COVID tests, staffing and cases of COVID in the community and hospital to be sure we have adequate resources to safely perform all scheduled outpatient services and surgical procedures," explains Craddock. "We will remain compliant with all social distancing guidelines for waiting rooms and masking of patients. We'll be maintaining the current visitor policy restrictions and the separate, negative pressure Respiratory Care Unit to care for COVID positive and pending patients apart from the general patient population."
Some of staff that at Augusta Health have been redeployed to other roles, and many of them will now be able to return to their home departments. Some of the new Covid-19-related positions, however—such as the nurses in the COVID Care Call Center, the screening staff at entrances and the Safety Resource Officers—will remain in place as part of maintaining a safe environment.
"The process of reopening these services safely for our patients and staff requires a well-orchestrated approach," says Craddock.
What should patients waiting for a procedure or Surgery do?
Augusta Health's providers will be calling their patients to schedule procedures and surgeries that were delayed by the temporary restrictions on elective procedures. The medical offices will provide instructions to patients, including which patients will require COVID-19 testing, where to go for the testing and if the patient will need to quarantine before the surgery or procedure.
"We'll be using a phased and flexible approach, based on CMS and AHA guidance, to resume our elective procedures," explains Craddock.
The three phases are:
Procedures that do not require testing, additional PPE, sedation or intubation began on May 6.
- The first outpatient procedures resumed are diagnostic radiology and diagnostic cardiology.
- Radiology has opened up screening exams such as LDCT lung cancer screening, screening mammograms, and non-emergency diagnostics like x-rays, CTs, MRIs, ultrasound and nuclear medicine exams.
- Cardiology has reopened Cardiac/Pulmonary Rehab, echocardiograms, vascular ultrasound, cardiac stress tests, and the Device Clinic. They are contacting patients who had procedures postponed.
- Augusta Medical Group practices have been scheduling patients when they can safely be seen, and encourage patients to call their provider if they have questions or concerns.
- The Center for Cancer and Blood Disorders has resumed routine follow-up visits that had been deferred.
- If these are successfully resumed, the Skilled Nursing Floor and Inpatient Rehab Floor will reopen and Pain Clinic will begin procedures.
For Phase I to be successful, procedures and visits will be safely resumed, supply and staffing levels will be maintained, and a low prevalence of COVID in the community and hospital will be sustained. When these criteria are all maintained, Augusta Health will move to Phase II.
Procedures that require pre-procedure testing of the patient for COVID-19. The testing protocol will include quarantine prior to surgery.
- The procedures include Outpatient Surgery, Endoscopy, Cath Lab, Sleep Lab, and Inpatient and Outpatient Invasive Radiology Procedures.
For Phase II to be successful, procedures and surgeries will be safely resumed, supply and staffing levels will be maintained, a low prevalence of COVID in the community will be sustained, an adequate stock of PPE will exist and inpatient beds will be available. When these criteria are all maintained, Augusta Health will begin Phase III.
Phase III will include Inpatient Surgeries. These procedures will all require pre-procedure testing of the patient for COVID-19. The testing protocol will include quarantine prior to surgery.
Projections are that the phased approach could take four to six weeks to complete, depending upon the monitoring of the indicators and criteria.
Social distancing in both Augusta Health and the community are keys to keeping the indicators strong and continuing to meet the criteria for advancing the phases. It's important for everyone to help keep those who have been waiting for healthcare to avoid exposure to COVID-19 and cause further delays. Keep patients—and each other—safe and healthy!