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COVID-19 and elective surgical procedures: Seven tips for a smart OR restart

April 27, 2020 Article 6 min read
Sharon Ulep
Following epidemiological guidance, ORs across the country closed their doors to elective surgical procedures amid the COVID-19 outbreak. As you plan to reopen, consider these seven tips to keep operations running smoothly and protect your staff and patients.
Empty operating room

Responding to the COVID-19 pandemic required extreme measures by ORs throughout the nation to address the crisis at hand, including a recommendation from CMS, the U.S. Surgeon General, and many other renowned medical groups to temporarily suspend and cancel elective surgeries and procedures. Many healthcare organizations and hospitals responded appropriately, postponing or cancelling nonessential surgeries.

Fortunately, we’ve started seeing signs that the first wave of this pandemic might be coming to an end, and organizations are starting to create project plans for resuming elective surgeries and procedures. The American Society of Anesthesiologists (ASA), the American College of Surgeons (ACS), the Association of periOperative Registered Nurses (AORN), and the American Hospital Association (AHA) have released a joint roadmap and list of considerations for resuming elective procedures after the COVID-19 pandemic.

Nearly 40% of the patients were unwilling to schedule their procedure at this time.

The time is now to begin planning for how ORs should address the overflowing case demand and backlog of surgical procedures that were cancelled due to COVID-19, as well as the normal surgical demand. We’ve outlined seven considerations for restarting your ORs and addressing elective case backlog. It’s important to note that your backlog is a combination of cases that have been cancelled as result of COVID-19 as well as cases that were in the pipeline at surgeon offices that were never put on the schedule due to the pandemic.

1. Put patient and staff safety first.

The number-one consideration to factor into resuming elective surgeries is patient and staff safety. Hospitals should aim to book surgeries at least 14 days out, 10 at a minimum. Patients being added to the surgical schedule should automatically be tested for COVID-19. If their results come back positive, they should be removed from the schedule and reschedule only once they’ve tested negative, twice. Once a patient’s surgery has been scheduled and they’ve been tested for COVID-19, the patient should then be instructed to self-isolate from then until their procedure date.

2. Create a COVID-19-specific cancellation code.

It’s important to understand the number of cases that have been or will be cancelled due to COVID-19, for both reporting purposes and beginning to address surgical case backlog. Once you’ve created a COVID-19-specific cancellation code, take a retrospective look at all of your cases since the pandemic started (we’d recommend at least March 15) and re-code cancellations that are particular to COVID-19. This can help identify cases that still need to be done and will allow your surgical team to appropriately estimate OR demand in the coming months.

3. Evaluate your OR demand and capacity.

Create a pipeline report by surgeon and specialty that identifies projected cases and case time needed to complete backlog cases. Backlog cases are those that were canceled by the hospital due to COVID-19 and those that were never scheduled by the surgeon’s office. Evaluate the case times, turnover times and needed hours of block to complete the backlog for each surgeon. This will be important as your OR adjusts blocks and times during the restart period.

Additionally, evaluate your OR capacity during current primetime hours and consider extended hours with a goal of optimal utilization to address the current backlog of cases.

4. Prioritize cases using a scoring system, such as the Medically Necessary Time-Sensitive (MeNTS) scale.

A scoring system will help with determining how to prioritize cases and when to proceed with certain surgical operations in light of resource limitations and exposure risks posed by COVID-19.

The MeNTS prioritization scale’s methodology, developed by investigators and surgeons at the University of Chicago, addresses elective surgical procedures and guides both surgeons and OR leaders across different specialties in prioritizing case types and patient safety. There are 21 factors considered in the scoring system, scored on a scale of 1 to 5. Thus, a total score can range from 21-105. The higher the score, the greater the risk to the patient, the higher the utilization of healthcare resources, and the higher the chance of viral exposure to the healthcare team.

This system is ideal for any OR, not just academic medical centers or large health systems. The assessment of resources and risk is applicable anywhere, which makes this a strong tool for prioritizing and determining cases to go forward with amid the COVID-19 pandemic.

5. Develop individualized plans to adjust blocks based on prior utilization and extend release times to accommodate a backlog of deferred cases.

There needs to be a concentrated effort to enforce block policies to ensure optimal efficiency and max utilization to accommodate a backlog of cases. OR leaders should consider extending block release times out by at least seven days (with cardiac and trauma being the exceptions to this) to allow specialty teams more flexibility in scheduling as the surgeon offices begin booking cases again.

Take some time to review your block utilization numbers from January and February. OR leadership should consider temporarily releasing blocks that had less than 50% utilization in January and February.

Additionally, consider a “Surgery Saturday.” This would require opening a couple of your ORs on a Saturday for high-volume surgeons with consistent case-time procedures. This would be for shorter cases like hernia repairs or similar cases (less than 45-minute case times).

6. Consider a modified visitor policy specifically for surgery patients.

A local hospital began contacting patients to schedule their canceled elective surgery and found that nearly 40% of the patients were unwilling to schedule their procedure at this time. Cases that would require an overnight stay were even more likely to be declined with the visitor restriction policy being cited as one of the driving factors. Fear and safety concerns are understandable and should be addressed with good policy and precautions. If you’re leading an OR at a hospital that doesn’t have any active COVID-19 cases or that can restrict cases to a specific floor or floors, it might be worth considering a modified policy for visitors. Testing and self-quarantine requirements used to keep surgical patients safe could be extended to a specific visitor for the purposes of a planned elective case.

7. Use CMS’ “Hospital without Walls” exemption to complete cases at an ambulatory surgery center (ASC) instead of the hospital.

Maximize volume of surgical cases in a way that promotes patient safety and preserves resources at the main hospital. This will also protect inpatient capacity at your main campus. The Hospital without Walls initiative allows currently enrolled ASCs to temporarily enroll as hospitals and provide hospital services. During this time, ASCs can bill procedures as if they’re being performed at the hospital.

For more information, ASCs that want to enroll to receive temporary billing privileges as a hospital should call the COVID-19 Provider Enrollment Hotline or review the CMS Medicare provider enrollment relief FAQ.

If you’re interested in learning more and collaborating with other OR directors facing the same challenges, consider joining one of our OR restart collaboratives. We’re hosting a collaborative session for hospital leaders, OR directors, and surgeons to discuss current issues and how to restart ORs amid the continuing COVID-19 pandemic. If you’re interested in participating or would like to learn more, please contact or For more information on this topic, check out our article at Fierce Healthcare.

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