Spine and orthopedic surgeries have been gradually moving away from the hospital setting toward ASCs well before the onset of the COVID-19 pandemic.
Five spine and neurosurgeons discuss how the pandemic will affect this trend.
Note: Responses are lightly edited for style and clarity.
Question: Will the COVID-19 pandemic drive more spine surgeries toward outpatient settings?
Scott Boden, MD. Emory Orthopaedics & Spine Center (Atlanta): The early recovery phase of the COVID-19 pandemic may divert some additional spine cases from hospital outpatient departments to free-standing ASCs because of a perception that those outpatient facilities may be COVID-19-free. In reality, proper personal protective equipment, screening, patient cohorting and hand hygiene should enable all healthcare facilities to remain COVID-19-safe. ASCs and their staff and patients will not be immune from COVID-19 given the community spread and high prevalence of asymptomatic carriers.
Andrew Hecht, MD. Mount Sinai Hospital (New York City): Much of the hospital to ASC shift in spine cases has already occurred, with many of the cases suitable for outpatient settings having already been moved there. Similarly, many hospitals are developing outpatient spine surgery programs that allow more rapid discharge. Trends toward less invasive spine surgery will undoubtedly continue to lessen the length of stay for many spine patients.
I think many ASCs will open before hospitals for spine care. Surgeons who do not routinely do surgery in an ASC may consider moving patient appropriate care to those types of outpatient settings. I think patient safety and careful patient selection should be the key factors when deciding what type of case is appropriate for an outpatient setting or ASC. The ability to have 23-hour observation, or transfer to a hospital if need be should be key factors as well. Equally important are the overall health status of the patient, risk of complications and likelihood of needing more than a day of hospitalization. Cases like lumbar microdiscectomy, single level laminectomy, cervical foraminotomy and one level ACDF remain excellent choices to be done in an outpatient setting for the healthy patient. However, many surgeries will still need the done in an inpatient setting. We may see an increase in surgeons doing appropriate cases in an ASC or outpatient setting, rather than changing the type of case that is performed.
William Rambo, MD. Midlands Orthopaedics & Neurosurgery (Columbia, S.C.): Pandemic pressure has increased patient awareness of ASC alternatives for all surgeries. Throughout the pandemic, many ASCs were able to safely offer spine surgeries needed to address significant neural compression or to relieve severe pain. Additionally, some hospitals have been slow to resume elective surgery as they remain focused on COVID-19 response and are still navigating staff shortages due to furloughs of critical support personnel.
As initial concerns about preserving PPE have abated, the smaller physical footprint of ASCs makes it easier to quickly implement, monitor and adjust new safeguards as community situations evolve. The daily COVID-19 news cycle reminds all Americans of the critical role hospitals play in treating infectious disease. Conversely, ASCs provide surgeries in highly specialized settings that do not co-mingle infectious patients with otherwise healthy patients with a specific surgical need. This distinction has always been true, but pandemic-related media coverage has enhanced this awareness among the general public. These factors coupled with the transition of spine surgeries to ASC settings — that was already growing quickly pre-pandemic — are likely to drive more spine surgeries to ASC settings.
Choll Kim, MD, PhD. Spine Institute of San Diego: The short answer is yes. More and more spine surgeries will be performed in the ASC setting. This is the natural evolution of all surgical specialties. The question is, and has been, when? The COVID-19 crisis, while devastating, may give us the needed "activation energy" to pursue this important effort, which in turn will stimulate advancements in MIS technologies, ERAS, cost efficiency, customer service, complication management, and most importantly greater surgeon engagement in facility operations. I see a perfect storm brewing. The COVID-9 crisis has brought it much closer to land.
Michael Smith, MD. Rothman Orthopaedic Institute (Philadelphia): A major opportunity we could take from the COVID-19 crisis is sharpening our drive to move the great majority of spine surgical care out of hospitals. A variety of cultural, institutional, financial and regulatory issues make it easy for many of us to keep operating in a hospital. It is comfortable for most of us; it is how most of us trained, and most of our learned professors had no reason to bother looking outside the hallowed halls. But we see a great limitation in our hospitals now as they have been suddenly and completely taken from us by a single virus. Hospitals are not specifically built to be optimized for spinal care.
ASCs, especially with an overnight nursing option, and facilities that can extend care for 1-2 postoperative days should be able to accommodate a significant majority of spinal care. Minimally invasive techniques support this transition. Surgeon ownership and management of these centers can build efficiencies for the physicians and the patients that are structurally impossible in a large and complicated hospital. For those of us who have really only known life in academic medical centers, where the surgeon's control of anything other than the actual cutting is very limited, could find this a brave and bright new world.