Restoring elective surgery caseloads post-COVID-19

The novel coronavirus/COVID-19 global pandemic changed nearly everything for healthcare organizations. For over six months, healthcare providers have reallocated their time, energy and resources to address the pandemic, leading to the creation of backlogs in many practice areas. Elective surgery, one of the most highly impacted areas, saw an especially high backlog of caseload.

According to two studies conducted by LeanTaaS, over 60 percent of surgical facilities are performing 30 percent or less of their surgical volume prior to the COVID-19 pandemic. Shortages in personal protective equipment, available beds, essential equipment and space, particularly negative pressure environments, delayed most every non-essential surgery for months.

Hospitals and Operating Rooms (ORs) are beginning to adjust their daily operations to make resources more generally available, and this post provides an overview of a seven-step approach to restoring elective surgery caseload.

Calculate the backlog

There are two important considerations to factor in addressing a facility’s backlog. First, there’s the working assumption that the vast majority of elective surgeries impacted by the pandemic will likely not dissipate, but rather be postponed. Secondly, there’s an understanding special measures will need to be taken during the COVID-19 recovery period to meaningfully increase OR throughput. After all, if post-pandemic OR throughput is similar to what it was before the pandemic, then the backlog will never be completed and the loss of case volume to other facilities could be significant. 

Calculating an OR’s case backlog requires three different inputs:

• Baseline monthly volume pre-COVID-19
• Percentage of baseline cases conducted monthly through the pandemic
• Length of time elective surgeries were postponed in response to COVID-19 

LeanTaaS provides an easy-to-use online calculator for approximating an OR’s backlog of cases. In using the calculator, consider the impact of ramping up an OR to address the case backload. If it’s anticipated, for example, that an OR will first recover 50 percent of its pre-pandemic volume for a week or two, then 75 percent for another couple of weeks before finally recovering 100 percent of its volume, either use midpoints for the calculator or run multiple simulations. 

The backlog calculator uses additional inputs that can be regarded as strategic levers in developing plans to address the backlog, including the percentage improvement in prime time utilization of the OR, the percent increase in volume expected by extending weekday hours, the number of weekend days to be added to the OR calendar, and the percentage of cases that can be diverted to ambulatory service centers (ASCs) and other procedure rooms. 

Lastly, input COVID-19-related variables that affect case load volume, like estimations for fewer trauma cases and yet other cases lost due to recession, lost healthcare insurance, etc.

Utilize the calculator to run simulations that estimate a facility’s backlog and how long it will take to fully recover. Change the inputs to see how different variables impact the overall recovery time. Based on the impact of those changed inputs, begin to develop key strategic considerations in building and executing upon an effective plan. 

Determine real surgical capacity (not just OR capacity)

Once the backlog is known and perioperative leaders know how many cases will need time made available, the organization next needs to evaluate capacity, both on the perioperative and OR side, as well as constraints on the availability of in-patient beds. 

When considering OR capacity and creating more time for case backlogs, several variables come into play:

• Block scheduling
• Ability to open more rooms
• Ability to divert to ASCs and procedural rooms
• Staffing constraints related to additional weekday hours and weekends
• Capacity of support teams, including sterile processing, packing, pre-op, etc. 

Partnering closely with in-patient teams to assess and understand bed constraints is critical. One outcome of the overall pandemic response is the implementation of daily, as well as multiple times daily, communication processes like crisis command centers, daily huddles and more. Moving forward and reincorporating elective surgical procedures require maintaining those close intra-system communication methods. Key communication points include:

• Number of beds available for surgical patients
• Number of beds absolutely off-limits to surgery patients
• Variances in bed needs due to day of the week
• Consensus on balance of to-be-admitted and out-patient cases

Prime importance is the understanding by both sides of the house on the needs and limitations of the other side. The inpatient team should have visibility into the data and needs of the OR, and the perioperative team should have the same to understand bed capacity. With freely accessible data and frequent, ongoing discussions, the entire healthcare system moves forward with peak efficiency and patient care effectiveness. 

Reevaluate block scheduling

To address the OR backlog in a timely manner, it will be critical to rethink block scheduling with the goal of maximizing utilization. Step one is a simple determination of whether or not temporary measures can be put in place to reallocate block schedules.

In surveying its customers, LeanTaaS has identified the following trends related to OR block scheduling during the pandemic:

• Most facilities are running a different block schedule during their recovery periods
• Most facilities have adopted a phased recovery plan, and are using a scaled down block schedule
• Some facilities have organized blocks at the service line level, letting each service line handle its own prioritization
• Some facilities have converted all non-acute OR time to open time, accommodating on a first come, first served basis

If possible, consider a temporary adjustment to block scheduling to catch up with the backlog. In addition, examine the ability – and potential impacts – of the following temporary initiatives:

• A reduction in the number of rooms running
• Non-COVID (clean) ORs and COVID (dirty) ORs
• Increases in the auto-release time

Lastly, in relation to scheduling, it’s important to note that many providers have not seen the usual number of patients in their clinics during the pandemic. Unlike the pre-pandemic “normal,” many providers have found better visibility into their own backlogs and their essential cases, and it’s important for perioperative leaders to collect that information. Managers and schedulers with the iQueue for Operation Rooms solution have that accessibility. 

Create easy processes for block release, discovery of availability and scheduling 

Once an organization has assessed its backlog, examined resource constraints on both the perioperative and inpatient sides, and reevaluated block scheduling, the next step is to develop processes that make it easy to conduct business with surgeons and their offices. 

With blocks released and made available, it becomes crucial to make the newly found available time visible and accessible to providers. There are systemic solutions, like iQueue for Operating Rooms, that automate this task and make open time both visible to offices and available for request with just a couple of clicks. However, in the absence of such solutions, healthcare organizations will have to piece together a variety of manual solutions to facilitate this two-way flow of information, including hallway meetings, phone calls, emails, texts and faxes. Paramount for administration will be timely updates to open time available – think online resources like Google Sheets – and a consistent stream of communication to offices detailing temporary processes and procedures. Lastly, ensure the communication is two-way in nature, and in particular place emphasis on the early release of block schedule if it’s not going to be utilized by its existing holder. 

Think easy: easy release of blocks, easy access to right-sized time periods for the right clinics, easy requests and approvals for time, and easy configurations around the constraints of the hospital. 

Execute as a single team

Step five is a reminder that it’s never been more important for the entire hospital system to act as a single team – there are simply too many demands pulling resources in different directions for a fractured organization to be effective. Within the perioperative suite, communication must be seamless with nurses, anesthesia, physicians and other stakeholders regarding block schedules, the release and rebooking of time, and processes to address the backlog, such as extended workday hours and the addition of weekend days. 

Across the hospital, executive support will prove critical in facilitating effective communication through ancillary departments, ensuring perioperative administration has visibility into in-patient management, and vice versa. 

Finally, consider third parties who are either affected by or who can themselves affect the temporary plans put into place, such as expanding schedules to weekend days. 

Measure, iterate and reiterate

Navigating into the previously uncharted waters of pandemic recovery requires a test, learn and improve mindset. A OR’s first plan to recover its backlog will almost certainly not be its last.

Create reporting mechanisms that allow insights to be developed every week or even couple of days. Seek measurements that provide actionable data on the following factors:

• Understanding of the ongoing extent of the backlog and any special needs (robotic rooms, etc.)
• Increased in case load accommodation versus the plan
• Realized increase in prime time utilization versus the plan
• Assessment of team member morale

Remember that each input into a recovery plan has an impact, with perhaps expected and unexpected consequences. Using tools like the one presented earlier, run different simulations with different levels of inputs and assumptions, and forecast the probable results. Set your strategies, but review data often to determine what adjustments and corrective actions need to be taken. However, keep in mind that changing just one of the administrative levers might well require a full organizational effort to first agree upon, and then executive upon, a revised plan. 

Prepare for subsequent waves

Lastly, it’s important to learn from the past and prepare accordingly. The image, below, shows the mortality rates in the United States of the 1918 flu pandemic. After an initial peak, incidents decreased significantly. Then, unfortunately, it peaked again during a second wave, one that produced more fatalities than the first wave.

The recovery from the COVID-19 pandemic has been slow, and as society has opened up, the country has experienced infection rates ramping up in some communities. The spread of the virus is ever-changing and dynamic, so healthcare systems will need to be diligent in reassessing their local situations and reiterating their utilization plans with a test and learn methodology.

Going forward

It’s our intent and our hope that the seven steps reviewed above provide a go-forward foundation for perioperative leaders in their elective surgery recovery planning. As an organization, LeanTaaS is committed to assisting the healthcare community as it addresses the pandemic and its aftermath. As you and your organizations move forward, LeanTaaS would like to understand your lessons learned, how the seven steps above helped or hindered your progress, and factors that need to be either added in or lessened in their priority. Please reach out to LeanTaaS at restore@leantaas.com to share your stories, ask questions or express concerns, and inquire about additional resources.

For more information on recovering your OR’s backlog, access the recorded webinar on demand, “Restoring Your Elective Surgery Caseload Post COVID-19.”