COVID-19: Provider roadmaps to restarting deferred procedures and visits hinge on PPE, testing and trust

Crystal Yednak Senior Manager, Health Research Institute, PwC US April 23, 2020

Several roadmaps to reopening have been released in recent days that detail paths for providers to restart deferred procedures and visits. CMS rolled out guidelines Sunday for hospitals in states that had met the criteria for Phase 1 of the White House’s guidelines for reopeningIndustry groups also released recommendations.

Meanwhile, this week, governors in Florida, Georgia, South Carolina, Tennessee and Oklahoma announced they would begin loosening restrictions they put in place in response to COVID-19 surges, a sign that reopenings in some states may happen sooner than anticipated.

According to the White House Guidelines for Opening Up America Again, states or regions can move on to Phase 1 if they have a decrease in influenza-like illnesses and COVID-19 “syndromic illness” cases over 14 days. They also should see a decrease in documented cases or in the percentage of positive tests over a 14-day period. Hospitals, the guidelines say, should be able to treat all patients “without crisis care” and have a robust testing program for healthcare workers.

Under CMS’ guidelines, hospitals can restart nonemergent services if they have “adequate facilities, workforce, testing, and supplies,” and doing so will not threaten area capacity to react to COVID-19 waves. CMS also recommends coordination with state and local public health officials, so health systems understand local COVID-19 trends.

Hospitals expanding services are advised to create zones for non-COVID care where any patient coming in would be screened for symptoms of the disease, according to CMS’ plan. Staff also would need to be screened regularly; patients would have to wear their own face coverings.

The guidelines emphasize that hospitals must have “sufficient resources” of personal protective equipment (PPE), workers and testing capacity but not hamper the rest of the operation’s ability to respond to COVID-19 cases.

In addition to separating non-COVID-19 and COVID-19 patients by facility, or floors, the guidelines recommend separating the staff as well, so personnel don’t mingle between zones. Procedures and plans should be put in place to allow social distancing in waiting areas, prohibit visitors and ensure appropriate sanitation.

“When adequate testing capability is established, patients should be screened by laboratory testing before care, and staff working in these facilities should be regularly screened by laboratory test as well,” according to the CMS guidelines.

The American Hospital Association, the American College of Surgeons, the American Society of Anesthesiologists and the Association of periOperative Registered Nurses released their own roadmap for resuming surgeries. Their plan also urges evidence of flattening of the curve of confirmed COVID-19 cases, with sustained reduction of new cases for at least two weeks. It also emphasizes that timing and accuracy of testing be factored into any planning.

HRI impact analysis

Some hospitals and health systems have experienced intense financial pressure as nonemergent procedures and visits evaporated from their schedules, and there are worries that people are deferring critical care. Some health systems announced in recent days that they are restarting some services offering necessary care and some outpatient surgeries to deal with pent-up patient needs. But the country’s testing and supply chain challenges could complicate efforts as hospitals grapple with expanding care and protecting workers and families through possible future waves of the virus.

Hospital struggles to obtain enough PPE and tests have been well documented by media and by the HHS Office of Inspector General, which conducted a survey of 323 hospitals between March 23 and 27 that found that severe shortages of testing supplies were thwarting their abilities to properly monitor patients and staff for the virus in order to prevent the spread. The report found hospitals were turning to paint supply companies, online retailers and other nontraditional sources.

This week, governors continued to argue that they lacked crucial supplies, with some turning to other countries, while a chief physician executive for a health system experiencing extreme shortages documented in NEJM his quest to procure three-ply face masks and N95 respirators for his staff—at five times the price they would normally pay—and then protect them from being seized by federal agencies. Representatives of a large nurses union protested at the White House on Tuesday, demanding more production of PPE.

A survey of primary care clinicians conducted between April 10 and 13 by the Larry A. Green Center and the Primary Care Collaborative illustrated the financial and supply pressures that continue to complicate their ability to do business.

In the survey, nearly half of clinicians said they were unsure if they had enough cash to stay open, while 34% said they had no capacity for COVID-19 testing and 32% reported limited capacity. As for PPE, 53% said they lacked it while 58% said they were relying on used and homemade PPE.

Even as providers in certain areas are able to get through the first gate, they still must confront how they can reassure the public that it’s safe to come back to the hospital. Healthcare organizations should consider developing proactive communication strategies to help build public confidence and determine which new tools that might help them keep patients safe. Policies and procedures that show that the hospital has thought through every step of the patient experience to ensure their safety will also help patients feel reassured. 

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Trine K. Tsouderos

HRI Regulatory Center Leader, PwC US

Tel: +1 (312) 241 3824

Crystal Yednak

Senior Manager, Health Research Institute, PwC US

Erin McCallister

Senior Manager, Health Research Institute, PwC US

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