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there are those patients you know will not be appropriate following a conver- sation. These might be patients with a history of chronic pain who have been on narcotics for a while and those who do not have a realistic view of the pain they


will experience following the


procedure. I am not going to approve a patient unless I’m 99.9 percent sure they can be safely discharged within our 23-hour, 59-minute timeframe.” Anesthesia providers at Ambulatory


Surgical Center of Stevens Point review every patient’s history and physical before signing off on a case. They are looking for any indication that a patient might not be appropriate, such as a high BMI, severe coronary artery dis- ease, COPD, valvular disease and other comorbidities, Wenman says. When a decision about whether to


proceed with a higher acuity case is not clear-cut, the anesthesia provider will review the case with the perform- ing surgeon, says Administrator Becky Ziegler-Otis, CASC. “They will go over the areas of concern and come to a consensus based on our guidelines.” Wenman adds, “You must be cau-


tious. You are better off postponing a procedure and getting an additional test or study completed than moving ahead if you are on the fence.” Cumberland Valley Surgery Cen-


ter’s criteria were established dur- ing meetings with the total joint team stakeholders prior to the inception of the program. Anesthesia, physicians and the ASC staff were involved with outlining the guidelines. “The origi- nal criteria are continually reviewed and adjusted as the center’s program has expanded and stakeholders gain further insight into the unique needs of our outpatient total joint program and its patients,” Sachs says. Even if all guidelines are followed and criteria are met, Flory says, ASCs should only proceed with a procedure if it meets one final requirement. “If a case does not pass the ‘smell test’—if


Guidelines for Elective Surgery After Recovery From COVID-19


In December, the American Society of Anesthesiologists (ASA) and Anesthesia Patient Safety Foundation (APSF) issued a joint statement on elective surgery and anesthesia for patients after COVID-19 infection. Included were suggested postponement times from the date of COVID-19 diagnosis to surgery.





four weeks for an asymptomatic patient or recovery from only mild, non-respi- ratory symptoms;


■ six weeks for a symptomatic patient who did not require hospitalization; ■





eight to 10 weeks for a symptomatic patient who is diabetic, immunocompro- mised or hospitalized; and


12 weeks for a patient who was admitted to an intensive care unit due to COVID-19 infection (current as of March 1).


These guidelines were issued at a time when there is a lack of abundant data concerning perioperative outcomes in COVID-19 patients, says Arnaldo Valedon, MD, medical director of outpatient perioperative management at WellSpan Health in York, Pennsylvania. Despite this, he says ASCs should consider implementing them.


“The reality is that we need more studies to validate recommended practices, but we are building the plane as we are flying it when it comes to many of the recommendations being issued concerning COVID-19,” he says. “While we do not have abundant data to guide us, we do know that the guidelines that were put out by ASA and APSF are reasonable and based on data to date.”


Valedon emphasizes that these guidelines should be applied to patients stable enough to have their surgical care delayed and not cases of an urgent or emer- gent nature. “For the guideline concerning patients with diabetes and being immunocompromised, we know those patients are especially at risk of having complications, which is why they have the longer suggested wait time.”


ASCs will want to keep an eye out for new findings concerning perioperative outcomes in COVID-19 patients, Valedon says. "We are now learning that even when patients are asymptomatic and have recovered from COVID-19, there is still the potential for many procedural issues and problems, particularly concern- ing the pulmonary and cardiac systems.”


“For now, the ASA and PASF guidelines should be viewed as prudent. But they are almost certainly going to change as we get more information,” he says.


you have a concern that something is just not right—you need the courage to cancel the procedure.”


ASCs interested in adding higher acuity cases should prioritize anes- thesia engagement, Ziegler-Otis says. “If you do not have anesthesia buy-in and the right anesthesia protocols in place, you are not going to have a suc- cessful program. Without that leg for our total joint replacement program, we would not be where we are today.”


Flory recommends that ASCs tar-


get specific types of patients for their first batch of higher acuity cases and choose the most healthy and straight- forward patients possible. “Do not tackle a larger patient with tough pain control. These can be more difficult cases and lead to some frustration for your team. An easier batch can help you ensure the guidelines in place and everything else you planned works as expected. Get some easy wins and then build on your success.”


ASC FOCUS MAY 2021 | ascfocus.org 13


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