By Phenelle Segal, RN, CIC, FAPIC, Founder and President, Infection Control Consulting Services

At the beginning of the COVID-19 pandemic in 2020, ambulatory surgery centers (ASCs) were severely impacted as state governors issued executive orders directing that essentially required all ASCs as well as hospitals; office surgery centers; dental, orthodontic and endodontic offices; and other healthcare practitioners' offices to immediately stop providing any medically unnecessary, non-urgent, or non-emergency procedures or surgeries.

The reason for suspending elective surgeries in outpatient surgical centers was to assess for surge capacity — use of outpatient beds to house ill patients — if hospitals began running out of beds, potential use of staff for hospital care, use of anesthesia machines to be converted into ventilators, and preservation of personal protective equipment (PPE) for the most medically necessary needs in hospitals.

During this "down time," facilities began developing COVID-19 response plans in anticipation of reopening while the threat of the coronavirus remained. When states began providing guidance for reopening ASCs, these plans needed to be put into effect.

Newly developed prevention practices based on CDC guidance included the following:

• Social distancing in waiting rooms, patient care areas, office space, and break rooms.

• Placement of additional hand sanitizer stations and increased environmental cleaning.

• Procuring more PPE supplies and understanding how to safely reuse masks.

• Development and implementation of patient and staff screening tools.

The reopening was slow and calculated as the nation continued to grapple with critical shortages of PPE and disinfectants, chaotic testing issues, and often confusing guidance from CDC and other bodies issuing recommendations. Patient hesitation to come out of their homes and spend several hours indoors played a significant role in the completion of fewer procedures than during a typical summer. Further complicating matters: Many ASC staff members were either too afraid to return to work or had moved on to find other jobs.

New reopening practices included the following:

• Universal masking of staff and patients.

• COVID-19 testing of patients prior to surgery (at the center or independent testing with a written result).

• Banning/restricting visitors.

• Screening staff and testing via point-of-care or polymerase chain reaction (PCR) methods.

• Contact tracing and staff quarantine.

• Updating guidelines and increased staff education.

The "new norm" continues with COVID-19 prevention practices shaping the future for improved health and wellbeing of patients and staff. Among them:

• Facilities should maintain ongoing preparedness strategies for future pandemics that historically occur every 4-6 years.

• Vaccination of employees and patients have greatly reduced the risk of acquiring severe illness, hospitalization, and death.

Pre-COVID and additional practices should be maintained by ASCs and other facilities. These practices include:

• Assessment and meticulous monitoring of the HVAC, filtration, and air exchange systems.

• Increased environmental disinfection and monitoring for compliance.

• Review of newer technologies for disinfection, such as ultraviolet options.

• Enhanced supply chain management with stockpiling strategies.

• Return to conventional capacity use of PPE.

• Increased surveillance for surgical site infections (SSIs).

• Increased compliance monitoring/auditing for hand hygiene and use of PPE.

At the time of this column, the pandemic continues to surge through the country (especially in the Southern states) with the highly transmissible Delta variant, particularly among the unvaccinated. Breakthrough infections are occurring among vaccinated personnel, with similar rates of spread as unvaccinated. However, breakthrough infection in vaccinated individuals is not resulting in severe illness, hospitalization, or death, except on rare occasions in high-risk persons. A CDC study found that unvaccinated people are about 29 times more likely to be hospitalized with COVID-19 than those who are fully vaccinated.

Due to the disparity in vaccination acceptance based on regions of the country, non-pharmaceutical interventions (NPIs) have been reinstituted in several states. While most of the prior practices are still in place in ASCs and other healthcare facilities, ICCS suggests that the following steps continue or be reconsidered.

• Daily screening of staff and patients should be continued (screening strategies individualized to the facility).

• Pre-operative COVID-19 testing of patients should be continued or reconsidered.

• Social distancing in waiting rooms should be continued.

• Universal masking for the entire building if people are congregating in common areas. Masks can be removed in breakrooms, but staff should be mindful of social distancing.

• N95 mask use during intubation or extubation.

As COVID-19 continues to mutate and with influenza season approaching in the late fall/early winter, ASCs should remain diligent and refer to CDC guidelines for handling of different situations as they arise. Vaccines should be encouraged for staff who are unvaccinated, and all staff should be offered the flu shot in the coming months.

If we hope to finally put the worst of COVID-19 behind us, we must all do our part by emphasizing safety and not putting our guard down.