With plans for re-opening, ACOG developed policies and processes to identify and consider how to safely resume care for non-COVID-19 related issues, such as preventative services, primary care, and non-urgent surgeries. As we prepare to open more services in Michigan, all OBGYN providers should be aware of the new position statement.
The American College of Obstetricians and Gynecologists is recommending numerous considerations to aid hospitals and health care systems as they develop and implement re-opening strategies. Re-opening will be a gradual process over an extended period, and routine care may not follow the same format as before the COVID-19 pandemic. Evaluate strategies to ensure that any novel approaches are safe, effective, and appropriate to incorporate into routine care. We have summarized the document for quick review; however, to review the full report, please visit ACOG Resumption of Comprehensive Women’s Health Care Policies and Processes Position Statement, May 6, 2020
Planning and Coordination
- Ensure strategies for a resumption of routine care are data-informed and coordinated.
- Resumption policies and procedures should be developed based on multidisciplinary communication, as well as concerns and challenges of each component of the health care delivery system.
- Follow a systematic, data-driven, and staged approach based on local, state, and regional considerations.
- Don’t expect that facilities or practices could resume care to pre-COVID-19 levels in a short time.
- Work collaboratively to determine the pace for resuming various aspects of routine care, while monitoring COVID-19 prevalence and use of resources, with adjustment of the pace as needed.
- Centers for Medicare and Medicaid Services (CMS) created suggested guidance regarding the timing of elective surgeries as well as nonsurgical care. Hospitals should not resume surgical scheduling until state or local regions meet “Gating Criteria.” This includes a downward trend in the rate of COVID-19 positive tests and patients with symptoms for at least 14 days, and hospitals must be able to treat all patients without resorting to crisis care, and robust testing in place for at-risk health care workers.
- Widespread availability and capability of reliable and accurate COVID-19 testing to develop and implement effective and safe resumption strategies and adjust to a phased approach as needed.
- Develop testing strategies relevant to patient populations and available resources:Patients that present to the labor and delivery unit, preoperative testing guidance, postoperative testing guidance, contact tracing to help prevent multiple community-level outbreaks.
- Maintain distancing in the early phases of resuming routine care. Ease restrictions based on accurate, robust local and regional data regarding the number of cases and transmission rates.
- Establish policies and procedures regarding physical distancing related to facility logistics, such as spacing of appointments, configuration of waiting areas, access and spacing related to services such as laboratory or radiology, and visitor and attendant policies.
- Develop policies for the use of masks and facial coverings. These policies should address whether all patients and clinicians will be masked during in-person encounters.
- Assess policies and procedures about physical distancing and related strategies on an ongoing basis. Modify the approach based on local and regional COVID-19 prevalence.
- CMS strongly encourages maximizing the use of all telehealth modalities.
- Consider incorporation of a phased approach to increasing non-urgent visits, with an emphasis on virtual visits early on and gradually increasing in-person visits.
- Account for the types of visits when planning virtual encounters.
- Consider maintaining telehealth in the provision of care on a more permanent basis, especially if services were safe, effective, and well-received by the patient community.
Preventative Measures (including PPE)
- Consider adequate supplies of appropriate PPE, with continual assessment and establishment of processes for maintaining an adequate supply.
- Continue training on the appropriate use of PPE.
- Develop preventative measures related to the management of in-person encounters. Considerations may include screening strategies for patients and visitors presenting for inpatient and outpatient services, such as pre-presentation screening (exposure, symptom screening by phone or telehealth visit), facility entrance screening (symptom, temperature check), and screening at check-in.
- Assess the supplies needed for patient care. Coordinate and collaborate within the health care system to identify supply chain support and maintenance strategy.
- Consider all personnel in resumption strategies.
- Staffing considerations should include coordination of scheduling to account for current workforce shortages due to COVID-19, optimizing PPE availability and use, and planning for contingencies should recurrent outbreaks develop.
- Recognize the impact of COVID-19 on health care professional wellness, including stress, fatigue, and potential for post-traumatic stress disorder (PTSD), as all involved recover from the pandemic professionally, personally, and emotionally.
- Monitor health care professional wellness and make mental health and wellness resources available to all members of the health care team.
Prioritization of Care
- Develop prioritization strategies for the resumption of patient care that has been postponed. These strategies could include care for pregnant women, care for women with signs or symptoms of malignancy, surgical care for patients with chronic or debilitating symptomatology, obstetric or gynecologic care for patients with comorbidities and chronic conditions that may require coordination with other services, care for patients for whom prior evaluation or interventions were either canceled or postponed and patients with new onset of symptoms or other considerations.
- Consider the effect of surgical timing on risk to life, organ system, or disease progression, as well as reproductive outcomes such as undesired pregnancy or increasing gestational age at the time of pregnancy termination.
- Additional considerations include the impact on patient’s well-being and quality of life, the use of health care resources, and the potential for patients losing health care coverage.
- A proposed scoring system for surgical patients may aid in prioritization consideration (Prachand et al).
- Collaborate and align prioritization strategies with applicable services. Prioritization should consider the impact of COVID-19 on disparities. Prioritization strategies should not exacerbate inequities.
- It is ethically unacceptable to use expected reimbursement as the primary determinant in resuming care and would exacerbate existing, and potentially create additional, health care inequities.
- Consider ongoing COVID-19 prevalence and threat assessment, including the adequacy of supplies, staff and practitioner wellness, coordination of priorities, resource utilization, patient access, and infection control. The assessment should involve a multidisciplinary team and include transparent two-way communication between the assessment team and members of the health care system. Incorporation of members of the patient community and any available patient-reported outcomes measures will benefit the ongoing assessment of a resumption strategy. Any modifications of resumption strategy should be to ensure patient safety and public health.
- Communicate with patients and the community as resumption policies and processes are implemented to clarify the need for a paced roll-out. Inform patients what they can anticipate with considerations that may include policies and procedures for ongoing COVID-19 testing, PPE policies for patients and the care team, family and visitor policies, and safety measures.
- Emerging data indicate disproportionate rates of COVID-19 infection, severe morbidity and mortality in communities of color, particularly among Black, Latino, and Native American people. Social determinants of health, current and historical inequities in access to health care and other resources, and structural racism contribute to these disparate outcomes. Recognize that some patients may have experienced new or exacerbated challenges during this pandemic, such as loss of employment and insurance coverage, food instability, inability to take advantage of social distancing guidance, difficulty accessing needed supplies, and unstable housing.
- Know the impact of health care inequities during attempts to resume to pre-COVID-19 levels. The same social and structural determinants of health that contribute to disparities in COVID-19 outcomes may influence the distribution of health care resources and patients’ access to health care. Policies and processes for the resumption of care, including access and prioritization, absolutely must account for these factors as not to further contribute to disparate outcomes or create additional inequities.
This situation evolves rapidly; please use the resources listed below for up to date information.
- ACOG Resumption of Comprehensive Women’s Health Care Policies and Processes Position Statement, May 6, 2020
- Center for Medicare & Medicaid Services Recommendations Re-opening Facilities to Provide Non-emergent Non-COVID-19-Healthcare: Phase I
- Medically Necessary, Time-Sensitive Procedures: Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic Prachand, Vivek N. et al. Journal of the American College of Surgeons, Article in Press