WASHINGTON -- Healthcare facilities should be able to begin performing elective procedures again if they follow certain protocols, according to by the Centers for Medicare & Medicaid Services (CMS).
Although many hospitals and health systems have quickly set up telehealth services to address non-urgent medical issues, "the reality is that not everything can be addressed by telehealth," CMS administrator Seema Verma said at a briefing held by the White House's coronavirus task force, citing breast cancer surgery and cataract surgery as two examples of elective procedures that can't be put off for too long.
With some hospitals around the country seeing a decline in COVID-19 cases and reporting unused capacity, "we're issuing guidelines today about how we can re-open the healthcare system; these are recommendations around Phase 1," Verma said, referring to the administration's "." That guidance outlines a stepped approach to resuming normal activities based on trajectories of syndromic illnesses, diagnosed cases, need for hospital "crisis care," and testing availability.
"Every state and local official has to assess the situation on the ground," she said. "They need to be able to screen patients and healthcare workers for the COVID virus, and we need to make sure that patients feel safe when they come in to seek healthcare services by showing they have the appropriate cleaning in place and that they observe social distancing inside the healthcare facilities." Verma added that this will be a gradual process in which "healthcare systems across the country need to decide what services should be available. We want to make sure systems are reopening so they can stay open, and doing that in a very measured way."
The new CMS guidelines specify that "non-COVID-19 care should be offered to patients as clinically appropriate and within a state, locality, or facility that has the resources to provide such care and the ability to quickly respond to a surge in COVID-19 cases, if necessary. Decisions should be consistent with public health information and in collaboration with state public health authorities."
Once the facility has reopened to patients needing elective procedures, "evaluate the necessity of the care based on clinical needs," the guidelines state. "Providers should prioritize surgical/procedural care and high-complexity chronic disease management; however, select preventive services may also be highly necessary."
As for getting the practice ready to accept patients, "Consider establishing Non-COVID Care (NCC) zones that would screen all patients for symptoms of COVID-19, including temperature checks. Staff would be routinely screened as would others who will work in the facility (physicians, nurses, housekeeping, delivery and all people who would enter the area)," according to the guidelines. "Sufficient resources should be available to the facility across phases of care, including PPE [personal protective equipment], healthy workforce, facilities, supplies, testing capacity, and post-acute care, without jeopardizing surge capacity."
In addition to a NCC zone for screening, the guidelines recommend that "in a region with a current low incidence rate ... the facility should create areas of NCC which have in place steps to reduce risk of COVID-19 exposure and transmission; these areas should be separate from other facilities to the degrees possible (i.e., separate building, or designated rooms or floor with a separate entrance and minimal crossover with COVID-19 areas)."
"Within the facility, administrative and engineering controls should be established to facilitate social distancing, such as minimizing time in waiting areas, spacing chairs at least 6 feet apart, and maintaining low patient volumes," the authors write. "Visitors should be prohibited, but if they are necessary for an aspect of patient care, they should be pre-screened in the same way as patients."
The guidelines also address PPE for patients and staff. "CMS recommends that healthcare providers and staff wear surgical facemasks at all times. Procedures on the mucous membranes including the respiratory tract, with a higher risk of aerosol transmission, should be done with great caution, and staff should utilize appropriate respiratory protection such as N95 masks and face shields. Patients should wear a cloth face covering that can be bought or made at home if they do not already possess surgical masks."
The American Hospital Association (AHA) praised the guidelines. "We welcome and support today's guidance from the CMS, which complements the work that the AHA has been doing with other partners in the health field, including the American College of Surgeons, the American Society of Anesthesiologists and the Association of periOperative Registered Nurses ," AHA President and CEO Rick Pollack said in an emailed statement.
"This CMS guidance is clearly focused on addressing important health care needs for non-COVID patients, with decisions being made by providers in collaboration with local and state public health leaders. CMS also rightly expects hospitals and health systems to maintain the flexibility needed to quickly respond to a surge should one occur in their community, and to maintain separate caregivers and locations within a facility for non-COVID care."
In addition to the elective surgery guidelines, CMS also said it will soon issue new transparency rules for nursing homes. "It's important that nursing home patients and their families have the information they need," said Verma. "We're requiring nursing homes to report to patients and families if there are cases of coronavirus inside the nursing home. We're also requiring them to report directly to the CDC when they have cases of coronavirus."
"Current requirements ... and CDC guidance specify that nursing homes notify state or local health department about residents or staff with suspected or confirmed COVID-19, residents with severe respiratory infection resulting in hospitalization or death, or ≥3 residents or staff with new-onset respiratory symptoms within 72 hours of each other," noted a to state survey agency directors from the director of CMS's Quality, Safety, & Oversight Group.
"At present, these data are not collected by CMS, CDC, or the Federal Emergency Management Agency (FEMA) ... The required collection of this information will be used to support surveillance of COVID-19 locally and nationally, monitor trends in infection rates, and inform public health policies and actions," and it will be available to the public.