Dr. Dave Campbell
Morning Joe Chief Medical Correspondent
Hospitals around the country are preparing for an influx of coronavirus cases that may require critical care, including ventilators. To handle the increased volume of patients that could potentially overwhelm hospitals Surge Capacity Protocols, we can turn to ambulatory surgery centers (ASCs) as part of a mitigation plan. Expectations are for the coronavirus pandemic to worsen. The United States can prepare for the worst while hoping for the best and by turning to an already established means of healthcare service.
The United States healthcare infrastructure needs to be concerned with three factors: Space, Personnel and Equipment to prepare for the inevitable rise in coronavirus infected patients.
“The capacity of this government to fully understand the impact of COVID-19 on this nation,” Dr. Leslie Diaz, Infectious Disease Medical Director for Foundcare AND Chair of Infection Control, Palm Beach Gardens Medical Center said Wednesday March 18. “Is equivalent to a 5-year-old trying to solve a calculus problem.”
There are 5,800 ASCs across the United States. We can co-opt and expand these facilities to provide additional space, personnel and equipment to help expand Surge Capacity and provider care services.
Surgery centers can unload the demand for space, personnel and equipment for hospitalized COVID-19 care by expanding outpatient care for URGENT ELECTIVE procedures.
To increase hospital bed and room availability early in the pandemic, Medicare, Medicaid and private insurance companies can give special authorization for additional urgent elective procedures to be completed in ASCs, rather than in hospitals. Currently, many surgeries are only authorized to be performed in hospitals. By loosening this restriction, hospitals will keep additional hospital beds available to handle the influx of coronavirus patients as they arise. Some acute medical conditions cannot wait for the hoped-for summer lull in the coronavirus pandemic. In the field of orthopaedic surgery, just a few of these may include spinal cord or nerve damage due to trauma, tumors, or large disc herniations, broken arms and legs, and much more. Other surgical fields have their own list of conditions that create indications for urgent elective surgery. One administrator for a large company managing scores of ASC’s said there may be up to 1000 procedures that could be specially authorized by the Centers for Medicare and Medicaid Services (CMS) or private insurance companies for completion in ASCs.
To further increase space needs later if, Heaven forbid, the pandemic progresses and overburdens hospitals Surge Capacity and intensive care capacity. We can use ASC’s as TRIAGE STATIONS. County Emergency Management Plans already in place might call for such contingencies. Commandeering surgery centers is a drastic step no one wants to consider, but must be, if sick patients are subjected to rationing of care or wind up laying in the hallways of hospitals gasping for air.
Healthcare workers represent the personnel that must be protected in a crisis of this magnitude. Many ASC employees have hospital experience. They can work harder and longer hours to lighten the load on those healthcare workers still working in hospitals. In China, like in all outbreaks, exhausted healthcare workers with inadequate Personal Protection Equipment, (eye protection, masks, gloves and gowns) are at higher risk of infection. Young doctors in China have died, despite the proclamations that only the old and immunocompromised die.
Patients that are seriously ill require extensive face to face time with doctors, nurses and other support staff in hospitals. The potential for repetitive exposure with multiple infected patients and higher levels of viral load exposure creates grave risk for healthcare workers. And they know it and still get up and go to work every day, unless they are also sick. When a healthcare worker on the front line of this battle against the coronavirus gets sick, they are no longer available to provide care, and many will need to be hospitalized themselves, further compromising space, personnel, and equipment shortages.
We need to protect healthcare workers like gold, a precious, invaluable resource.
To address the need for equipment, it is the tragic reality that ventilators are not readily available on the world-wide market for the United States. Other countries with more advanced numbers of critically ill, and countries that experienced dramatic increases in COVID-19 infections have already bought them up.
War Powers to ramp up ventilator production in the United States exists but have not yet been implemented by Presidential Decree.
Anesthesia machines such as those in ASCs have a specific design function that provides ventilatory support for surgical procedures lasting up to 24 hours. Speaking in general terms, and clearly stating that more research is needed, extended use is possible and can be explored by manufacturers, anesthesiologists and respiratory technicians. Co-opting anesthesia machines and personnel for the acute ventilatory support of coronavirus victims is a possibility. This alternative practice has not been discussed in reports I have seen from the American College of Surgeons, the Centers for Disease Control and Prevention nor the Ambulatory Surgery Center Association. Experts have cautiously advised me that if anesthesia machines begin serving as ventilators for COVID-19 patients, the machines would need more frequent mechanical and systems support than the ventilators used in the intensive care unit. No one has recommended this, yet, but consideration for using ventilators and staff in ASC’s for the overflow of COVID-19 patients that have no where else to go is worthy of a national discussion, even if it is shown not to be a workable solution.
Doing some quick math, 5800 ASCs’ with each ASC having a handful of anesthesia machines. ASC’s generally have two or more anesthesia machines. If we estimate five machines per ASC, just the purpose of easy math, since the exact number is not known to me, 5 x 5800 = 29,000 extra ventilators. Pulmonary distress in 5% of COVID-19 victims can become severe. These patients may require the assistance of a ventilator to help them breathe. Experts say we may run out of ventilators in the United States, like in Italy. The military may be activated to provide Combat Casualty care. The Strategic Stockpile of equipment is being dusted off as we speak. Military hospitals setting up in the parking lots of medical centers and hospitals are being discussed today.
I have spoken with experts in the field of anesthesiology as well as ASC management. All these sequential steps are feasible, or at least worthy of further consideration.
The Ambulatory Surgery Center Association published its additional guidance March 18. COVID-19: Guidance for ASC’s on Necessary Surgeries, is relevant for all Americans, whether they think they need surgery or not. It speaks to the urgency for mitigation of disease transmission in every state. It states:
…A surgery may be deemed urgent and necessary if the treating physician decides that a months-long delay would increase the likelihood of significantly worse morbidity or prognosis for the patient. First and foremost, if a procedure can be safely postponed without additional significant risk to the patient, it should be delayed until after the pandemic. The current and ongoing efforts to isolate our population and create social distancing are essential steps in saving lives by shortening and ultimately ending the COVID-19 pandemic. We concur with the American College of Surgeons that “the risk to the patient should include an aggregate assessment of the real risk of proceeding and the real risk of delay, including the expectation that a delay of 6-8 weeks or more may be required to emerge from an environment in which COVID-19 is less prevalent.
President Trump told several governors during a conference call on Monday, that they are primarily on their own in stocking up on gear such as respirators and ventilators to fight the novel coronavirus. President Trump said:
“Respirators, ventilators, all of the equipment—try getting it yourselves, we will be backing you, but try getting it yourselves. Point of sales, much better, much more direct if you can get it yourself.”
Governors can “try getting it yourselves,” they just need to look and think outside the box, at the ASC’s in their State.