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May 6, 2020

ACOG recognizes the importance of using a data-driven approach to base decisions regarding re-opening specific areas and services. Practices, hospitals, and health care systems are beginning to identify and consider how to safely resume care for non-COVID-19 related issues, such as preventive services, primary care, and non-urgent surgeries. The U.S. Centers for Disease Control and Prevention (CDC) advises that in order to safely curtail self-isolation efforts and keep America open, states, tribes, localities, and territories must be able to quickly identify new cases, break chains of transmission, and protect first responders and health care workers from infection.

Based on the array of types of care that obstetrician-gynecologists provide, the obstetrician-gynecologist community faces multiple challenges in developing re-opening strategies, including antenatal care, inpatient obstetric and gynecologic care, postpartum care, well-woman and preventive service visits, emergency, urgent, and nonurgent gynecologic care, and surgery. We acknowledge that resumption of women’s health care to pre-COVID-19 approaches is largely a local, state, and regional process that will vary based on a number of considerations, including local, state, and regional COVID-19 prevalence, availability of testing and personal protective equipment (PPE) supplies, patient needs, COVID-19 effect on the health care workforce, local logistics and physical plant characteristics such as bed space and intensive care unit (ICU) availability, and others. While a single universal approach is unrealistic, a number of considerations are available to aid hospitals and health care systems as they develop and implement re-opening strategies (examples included below). Further, we acknowledge that re-opening will be a gradual process that happens over an extended period of time. Additionally, routine care may not follow the same format as was common before the COVID-19 pandemic, particularly considering the adaptations in the provision of care during the pandemic such as expanded use of telehealth. Strategies implemented to provide care during the COVID-19 pandemic should be evaluated to ensure that any novel approaches are safe, effective, and appropriate to incorporate into routine care.

In addition to these general considerations, ACOG maintains a series of resources specific to COVID-19. ACOG will continue to update this page to include pertinent re-opening resources as information and example strategies specific to women’s health and obstetric care become available.

General Considerations

Planning and Coordination

In developing strategies for resumption of routine care, it is critical that these strategies are data-informed and coordinated across the applicable environment, whether it be the inpatient or outpatient setting. Resumption of health care to pre-COVID-19 levels is a challenge for the entire health care system, and all involved, including leadership, clinicians, staff, administration, support personnel. There is also a need to coordinate efforts and work collaboratively in developing and implementing data-driven resumption strategies. Resumption policies and processes should not be dictated by any one group, but rather developed based on respectful multidisciplinary communication that takes into account the best available data, as well as the concerns and challenges faced by each component of the health care delivery system in re-employing the full spectrum of care.

Timing

Resumption of women’s health care needs to follow a systematic, data-driven, and staged approach based on local, state, and regional considerations. It should not be expected that facilities or practices could resume care to pre-COVID-19 levels in a short time span because of the vast impact of COVID-19 on the entire health care system. Practitioners, hospitals, and facilities will need to work collaboratively to determine the pace at which various aspects of routine care can be resumed, acknowledging that monitoring of both COVID-19 prevalence and use of resources will be necessary and the pace adjusted as needed.

The Centers for Medicare and Medicaid Services (CMS) has released suggested guidance regarding timing of resumption of elective surgeries as well as non-surgical care. CMS recommends that hospitals should not resume surgical scheduling until the state or local regions meet “Gating Criteria”, which include a downward trend in the rate of COVID-19 positive tests and patients with symptoms for at least 14 days, that hospitals must be able to treat all patients without resorting to crisis care, and must have robust testing in place for at-risk health care workers, including emergency antibody testing.

COVID-19 Testing

Acknowledging that re-opening strategies should be data-driven, widespread availability of reliable and accurate COVD-19 testing is critical as practitioners and facilities gather the necessary data needed to develop and implement effective and safe resumption strategies. Testing is important for surveillance as well as protection of patients, staff, and practitioners. Because resumption of routine care is dependent on a number of factors, including local, state, and regional COVID-19 prevalence, widespread testing capabilities are essential to monitor and to inform adjustments to a phased approach in resuming routine care.

Facilities and practitioners will need to develop testing strategies relevant to their patient populations and available resources. Related to women’s health care, these considerations include strategies for testing patients who present to the labor and delivery unit and strategies for patients scheduled for surgical procedures, including preoperative and postoperative testing guidance. Given the potential for asymptomatic viral shedding, the approaches to testing may incorporate more widespread testing for COVID-19 in the early phases of resuming routine care, with possibly less widespread testing, based on symptoms or other indications, as local, state, and regional prevalence declines and is consistently maintained at low levels in the community.

Related to testing and surveillance is the ability to conduct contact tracing, which involves identification of contacts of those individuals who have tested positive for COVID-19 and follow testing and isolation recommendations accordingly (CDC, IDSA/HIVMA). Contact tracing is an important method to help prevent multiple community-level outbreaks. 

Physical Distancing

Physical distancing needs to be maintained in the early phases of resumption of routine care.  Any easing of physical distancing restrictions should be based on accurate, robust local and regional data regarding number of cases and transmission. The surveillance, as previously described, is a critical component to gathering the data needed to make decisions on how to safely ease physical distancing restrictions in order to demonstrate consistent reduction in the number of cases and potential for transmission.

In addition to overarching policies regarding physical distancing, practitioners and health care facilities will need to establish policies and procedures for maintaining physical distancing related to facility logistics, such as spacing of appointments, configuration of waiting areas, access and spacing related to services such as the laboratory or radiology, and visitor and attendant policies. Practitioners and facilities will also need to develop policies for use of masks and facial coverings; for example, in the early stages, policies should address whether all patients and clinicians will be masked during in-person encounters. Ongoing assessment of policies and procedures related to physical distancing and related strategies is recommended in order to modify the approach depending on local and regional COVID-19 prevalence.

Telehealth

The Centers for Medicare and Medicaid Services (CMS) strongly encourages maximizing use of all telehealth modalities. The COVID-19 pandemic has resulted in a number of policy changes designed to enhance implementation of telehealth; it is likely that some of the telehealth implementation strategies can be maintained in a resumption of care process. Consideration may be given to the incorporation of a phased approach to increasing non-urgent visits, with an emphasis on virtual visits early on and gradually increasing in-person visits. Planning for virtual visits must account for the types of visits that could be conducted virtually, recognizing that aspects such as physical examination, radiology, or laboratory testing would require an in-person visit. Some systems may 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.

Preventive Measures (including PPE)

Adequate supplies of appropriate PPE are an essential consideration in developing safe resumption of routine care strategies. PPE supply will need to be continually assessed and processes established for maintaining an adequate supply of PPE. Training on appropriate use of PPE is also essential to maintain.

In addition to PPE, preventive measures will need to be developed related to the management of in-person encounters, particularly in the early stages. 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), screening (symptom, temperature check) at the entrance to the facility; and screening at check-in.

Supplies

Safe resumption of routine women’s health care will require adequate supplies needed for the various aspects in providing care as well as incorporation of strict infection control policies. This consideration includes assessment of supplies needed for outpatient care, inpatient nonsurgical care, and surgical care. Considering that these resources may be shared with other departments or entities within the health care system, it is important to collaborate with these other departments and entities to identify an appropriate supply chain support and maintain the resumption strategy.

Personnel

Ensuring that all personnel, including physicians, nurses, staff, administration, and other persons depending on the practice situation, are considered in the resumption strategies is critical to a successful implementation. Staffing considerations, particularly in the early stages of resumption strategies, 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. It will also be critical to recognize the impact of COVID-19 on health care professional wellness, including stress, fatigue, and the potential for post-traumatic stress disorder (PTSD), as all involved in the health care system recover from the pandemic professionally, personally, and emotionally. In addition, institutions must recognize that besides the demands of clinical care, clinicians and staff may be simultaneously managing challenges related to securing child and other dependent care and expectations regarding homeschooling. Monitoring health care professional wellness and making mental health and wellness resources available to all members of the health care team are key components of long-term sustainability of a resumption strategy.

Prioritization of Care

In scaling up routine health care services, there will be a need to develop prioritization strategies for resuming patient care that has been postponed. For women’s health care, prioritization considerations for a resumption strategy may include care for pregnant women, care for women with signs or symptoms suspicious for 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, patients with new onset of symptoms and other considerations. The effect of surgical timing on risk to life, organ system, or disease progression should be considered, as should reproductive outcomes such as undesired pregnancy or increasing gestational age at the time of pregnancy termination. Additional considerations include the impact on a patient’s well-being and quality of life, use of health care resources, and the potential for patients losing coverage for health care. A proposed scoring system for surgical patients may aid in the prioritization consideration (Pranchand et al). Importantly, while individual specialties and services may develop a prioritization system for their patients, it is important to collaborate and align prioritization strategies with applicable services that impact health care system utilization in the facility to coordinate care, such as nursing services, surgery, anesthesiology, or interventional radiology. In addition, any prioritization approach should consider the impact of COVID-19 on disparities and be applied to ensure prioritization strategies do not contribute to exacerbating inequities.

Because of the significant financial impact of COVID-19 on the health care system and patients, there may be pressure on the health care system to maximize revenue as health care services are scaled up and prioritized. Using expected reimbursement as a primary determinant in resuming care is ethically unacceptable and doing so would exacerbate existing and potentially create additional health care inequities.

Ongoing Assessment

It is crucial for facilities and systems to use a data-driven approach to review the multiple aspects involved in a resumption strategy. Aspects to consider include ongoing COVID-19 prevalence and threat assessment, adequacy of supplies including PPE, staff and practitioner wellness, coordination of priorities, resource utilization, patient access, and infection control, among others. This assessment should involve a multidisciplinary team and include transparent two-way communication between the assessment team and members of the health care system. Incorporating representatives from the patient community and any available patient-reported outcome measures will benefit the ongoing assessment of a resumption strategy and will be highly beneficial to ascertain whether patient needs are being met, to gauge public perception, and to enhance community engagement. The intent of any modifications of the resumption strategy should be to ensure patient safety and public health.

Patient Communication

Communication with patients and communities that institutions serve is essential as resumption policies and processes are implemented. Unquestionably, patients who have had access to care affected and have had care delayed or postponed will be anxious to receive needed care.  Clearly communicating the need for a paced roll-out of a resumption strategy is important, including communicating that prioritization is an important aspect of the system’s strategy, and what patients can anticipate as provision of health care begins to return to some semblance of “normal” to patients. Considerations may include policies and procedures for ongoing COVID-19 testing, PPE policies for patients and members of the health team, family and visitor policies, and safety measures being implemented. Partnering with community representatives may assist in communicating effectively with patients and to facilitate transparency. Clinical and public health messaging should be delivered in the preferred language of each patient and use of trained medical interpreters for clinical encounters.

Disparities

Emerging data indicate disproportionate rates of COVID-19 infection, severe morbidity, and mortality in communities of color, particularly among Black, Latinx, and Native American people. Social determinants of health, current and historic inequities in access to health care and other resources, and structural racism contribute to these disparate outcomes. It is also important to recognize that patients may have experienced new or exacerbated challenges during this pandemic, such as loss of employment and insurance coverage, food insecurity, inability to take advantage of social distancing guidance, difficulty accessing needed supplies, and unstable housing.

It is critical to recognize the impact of health care inequities during attempts to resume care 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 resuming care to pre-COVID-19 levels, including access and prioritization, absolutely must account for these factors as to not further contribute to disparate outcomes or create additional inequities. Institutions should also evaluate whether adaptations in the delivery of care implemented during the response to COVID-19 mitigated existing inequities and consider adopting these strategies beyond the pandemic response.

References

American College of Physicians. Internists identify essential elements to ease social distancing protocols, address White House guidance to “re-open” the U.S. Philadelphia, PA: ACP; 2020. Available at: https://www.acponline.org/acp-newsroom/internists-identify-essential-elements-to-ease-social-distancing-protocols-address-white-house. Retrieved May 7, 2020.

American College of Surgeons. Joint statement: roadmap for resuming elective surgery after COVID-19 pandemic. Chicago, IL: ACS; 2020. Available at: https://www.facs.org/covid-19/clinical-guidance/roadmap-elective-surgery. Retrieved May 7, 2020.

American College of Surgeons. Local resumption of elective surgery guidance. Chicago, IL: ACS; 2020. Available at: https://www.facs.org/covid-19/clinical-guidance/resuming-elective-surgery. Retrieved May 7, 2020.

Centers for Disease Control and Prevention. Contact tracing. Atlanta, GA: CDC; 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/php/open-america/contact-tracing.html. Retrieved May 7, 2020.

Centers for Disease Control and Prevention. Support for states, tribes, localities and territories. Atlanta, GA: CDC; 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/php/open-america/index.html. Retrieved May 7, 2020.

Infectious Disease Society of America, HIV Medicine Association. Policy and public health recommendations for easing COVID-19 distancing restrictions. Arlington, VA: HIVMA; Arlington, VA: IDSA; 2020. Available at: https://www.idsociety.org/contentassets/9ba35522e0964d51a47ae3b22e59fb47/idsa-recommendations-for-reducing-covid-19-distancing_16apr2020_final-.pdf. Retrieved May 7, 2020.

Prachand VN, Milner R, Angelos P, Posner MC, Fung JJ, Agrawal N, et al. Medically necessary, time-sensitive procedures: scoring system to ethically and efficiently manage resource scarcity and provider risk during the COVID-19 pandemic [published online April 9, 2020]. J Am Coll Surg DOI: 10.1016/j.jamcollsurg.2020.04.011