Dr. Mauricio Gonzalez is the Vice Chair of the Clinical Affairs Department of Anesthesiology at Boston Medical Center, and a Clinical Associate Professor at Boston University School of Medicine. He recently joined Hospital IQ for a leadership roundtable on reopening surgical services during COVID-19 recovery.
At Boston Medical Center, we have a list of at least 1,300 cases that were cancelled or postponed due to COVID-19. Although Massachusetts is not quite ready to begin opening back up and permitting elective surgeries again, our team is beginning to plan and prepare for that eventuality. We’ve begun thinking about how we’re going to pull people back from crisis scheduling to regular scheduling, and doing so in a mindful way without burning people out. They’ve been working very, very hard.
From the beginning, we shifted our whole department to different teams rather than rotating people around. This was for several reasons, but we felt it was important to have the people in the airway team be very facile about donning and doffing PPE to protect the workforce. It’s also a lot easier to inform a selected few and keep them current than try to keep the whole department updated. As the census goes down, the initial plan is to pull back the people who are on those teams and start folding them back into the main OR situation. That’s our phased approach to start restaffing the OR as needed.
One thing that we’re not yet sure about rotating back in, however, is the equipment. We deployed 12 anesthesia machines, the most sophisticated ventilators we had in the ICU, for COVID-19 treatment. We need to start pulling them back for surgery, but we stripped them of all the OR equipment that was not necessary in the ICU, like monitors and computers. All of that will need to be rebuilt and there’s also the question of decontaminating these machines. As our ICU situation improves, we’ll start taking one or two machines at a time and follow the manufacturer’s guidelines for sterilizing the internal components of the breathing circuit that may have come into contact with the patient’s exhaled gas.
We know our surgeons are eager to get these procedures started back up. They want to provide timely care to their patients and there are financial concerns for their practices. But they’ve been pretty busy themselves having been deployed in COVID capacities, so we will need to think as to how to roll them back into regular scheduling as well.
Our OR executive committee has laid the groundwork for this and started designating task forces to look at different portions. There is some work that is being done behind the scenes on the EHR side to optimize workflows for surgical schedules, OR scheduling, and for surgeons themselves to be able to get a grip on the cases that are sitting out there waiting to be done. We are also working on how we’re going to adjudicate priority for these cases.
We will also be working very closely with our supply chain experts and procurement. We have been experiencing shortages and supply problems with disposable airway equipment. I actually applied to the FDA for Emergency Use Authorization so we can re-sterilize those, and I’ve been in contact with Pharmacy as well. I know that we’re going to have issues with the propofol 100-mL vials, so we’ll probably have to curtail a little bit of TIVA.
The availability of blood is another concern. The Red Cross, at least locally, has been able to spread out the donation system enough to social distance and maintain some supply, but we’ve also been buying a very low amount. We need to give them notice so they can bulk up.
When the governor gives hospitals in our state the all clear, we’ll still want to do our best to keep the plateau we’ve achieved. Prior to any surgical procedures we will test patients 48 hours before and rapid test in the morning. The surgeon will also insist that the patient self-isolate for two weeks in advance.
This pandemic has created unprecedented challenges for hospitals and providers across the country, and it’s still undetermined when we’ll return to normal or if we’ll need to adjust to a new normal. But with careful planning, clear expectations, and open communication, we can continue to work through these issues.