Clinical, business flexibility called for during COVID-19 pandemic
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On March 11, 2020, with more than 118,000 cases reported in 114 countries, WHO characterized COVID-19 as a pandemic, marking it as the first pandemic caused by a coronavirus.
In the days that followed, WHO, CDC, CMS and other health care organizations continued releasing recommendations and guidelines for health care providers and the public to follow in terms of detection, protection, treatment and reduction of patients with COVID-19. This included CMS announcing the postponement of all elective surgeries, including non-essential medical, surgical and dental procedures to preserve the personal protective equipment (PPE), beds and ventilators that would be needed as the number of COVID-19 cases increased.
“Something has to be deemed emergent and/or delay of care has to translate to material adverse consequences. So, your elective rotator cuff surgery, elective ACLs, meniscus tears – they are all on hold,” John D. Kelly IV, MD, director of sports shoulder at Penn Perelman School of Medicine, told Orthopedics Today.
Although protocols may differ by hospital to state, sources who spoke with Orthopedics Today noted institutions are currently focused on emergency or trauma type cases that cannot wait 30 days or more without having a negative effect on the patient and possibly be limb threatening or produce permanent physical disability without prompt treatment.
The reasons behind these strict protocols are numerous, according to Michael D. McKee, MD, FRCS(C), president of the Orthopaedic Trauma Association and professor and chair of the department of orthopedic surgery at University of Arizona College of Medicine – Phoenix. The protocols are meant to help reduce the number of patients in the hospital who do not need to be there, leave hospital beds and resources open for patients with COVID-19, preserve PPE, and keep vulnerable or at-risk patients from developing infections from COVID-19 while in the hospital, he said.
“Hospitals tend to be the places where these conditions tend to congregate,” McKee, who is an Orthopedics Today Editorial Board Member, said. “That was certainly true for SARS in Toronto. I had the unpleasant experience of living through that back in 2003 ... and many of those infections, including infections to health care workers, occurred while patients were in doctors offices, in hospitals or other health care facilities.”
Urgent, non-urgent cases
In addition to trauma cases, postoperative infections or infections not preceded by a surgery are being considered urgent, Steven S. Shin, MD, executive vice chair of the department of orthopedic surgery at Cedars-Sinai Health System, said.
David A. Wong, MD, MSc, FRCS(C), said vascular complications from an orthopedic procedure are being treated as emergency cases.
However, Shin said pain is a “grey area” in terms of whether it is considered urgent.
“At this point, right now with how things are moving, we are not considering severe pain to be an indication [for surgery],” Shin, an Orthopedics Today Editorial Board Member, said. “We want to focus on preserving our supplies and equipment for those patients who need it.”
Patients with implant loosening, however, are being reviewed on a case-by-case basis to determine which need immediate surgery and which can wait, according to Ryan K. Harrison, MD, of Ohio State University Wexner Medical Center.
Although a loose implant may not be considered urgent, Wong said these could be cases in which a patient would require an X-ray.
“You have to have them come in and take an X-ray at some stage of the game to ... figure it out, but, once you have a firm diagnosis, that is where you have to triage who is in a life- or limb-threatening type of situation and who has a problem, but not an acute problem, that has to be dealt with on an emergent basis,” Wong, of Denver Spine Surgeons and an Orthopedics Today Editorial Board Member, said.
Additional protocols
In addition to the postponement of non-essential surgical cases, sources who spoke with Orthopedics Today discussed additional protocols being implemented by their hospitals and institutions.
McKee said they are carefully screening patients for COVID-19 prior to treatment and taking special precautions, such as using PPE among symptomatic patients. He explained they have separated the trauma team into several groups who do not come into contact with each other to reduce the risk of spreading COVID-19 among themselves.
“We have three or four separate teams of individuals who do not come in contact with each other and communicate over the phone or by Skype, so if one team goes down because it gets infected or contaminated by a COVID-positive person, and this is a real concern given the number of health care professionals who have become infected in various areas, then there is another team that can step in and keep the trauma unit and the fracture service open and the emergency cases going,” McKee said.
Shin noted Cedars-Sinai Health System has adopted modular clinic coverage to limit patient, physician and staff traffic inside its clinic. Two clinic doctors per week will be assigned to see all patients on the schedule whether it is within their specialty or not, according to Shin. All physicians will be asked to include an addendum to their notes regarding their plan for the patient, as well as to be available by phone or video during the patient visit to answer any questions the covering physician may have regarding the case, Shin said.
“We are not going to close. We are still a health care facility. We still have our duties and responsibilities to treat our patients,” Shin told Orthopedics Today. “The more we can do here to treat the urgent patients, the less patients will be seeking to go to the hospital for their care. Right now, the hospitals and the ERs are just overwhelmed, so we want to do what we can to lighten the load for the hospitals by staying open here and taking care of our urgent patients.”
The surgery center is also being used for orthopedic procedures that are urgent but do not require a hospital stay, such as hand surgeries, according to Shin.
“Right now, for my hand surgeons, if the patient can be most likely discharged the same day and the surgery is urgent, then we will try to push them to the surgery center to get it done,” Shin said. “The patient will have to have it done either way, but our thought process right now is that it is better to be done at a surgery center than at the hospital where patients are being directly treated for COVID-19.”
Increased patient volume
With hospitals and institutions focused on preserving PPE and resources, as well as maximally treating patients with COVID-19, rescheduling of postponed surgeries is not currently a priority, McKee said.
“We all recognize that there will be some pent-up demand for surgical intervention after the crisis stage is over,” he told Orthopedics Today. “We all recognize that and, fortunately in the United States, we are in a system where there is capacity and there is ability to accommodate that pent-up demand, that increase of surgeries that will happen.”
To help handle the possibility of increased case volume once the COVID-19 pandemic has been resolved, Harrison said he and his colleagues are placing their postponed cases into tiers organized by which cases need to be addressed first based on severity of disease. However, with no set timeframe for when elective surgical cases can be resumed, he said they do not yet know how elective surgeries scheduled for the second half of the year will be affected.
“The question that we do not know the answer to that has been brought up is, let’s say you have a surgery scheduled the third week in June. We have not canceled that surgery yet, so we do not know what the message is,” Harrison said. “Are we going to do those cases or are we going to go backwards and push everybody back? Those patients are potentially affected as well, and I do not think we know the right way to address that issue yet.”
One way the increased patient and case volume after resolution of the COVID-19 pandemic may be handled is through the extension of surgery hours, according to Kelly, who said surgical teams may also work to turn cases over faster to be able to fit more cases into the day.
“You do not want to overtax the system, but also recognize we have a delay of at least a 6- or 8-week case burden that has to be made up somehow,” said Kelly, who is an Orthopedics Today Editorial Board Member.
However, Wong noted OR time may not be the only issue after COVID-19. The availability of sufficient supplies, such as surgical masks and gowns, at an institution may be problematic, he said.
“We hear that they are trying to ramp up production, but whether they can ramp up rapidly enough that if we get the okay in 2 or 3 weeks to restart elective surgeries, right now, we are sitting in a time frame of 2 weeks where they might be completely run down to zero,” Wong said. “It is not like [hospitals] have a reserve that they can continuously ramp up the surgeries. They are going to have to wait until they get resupplied.”
Increased access to telemedicine
Having surgeries postponed and patients being asked to stay home led the Trump administration to expand Medicare telehealth coverage, allowing clinicians to provide telehealth services for Medicare beneficiaries across the United States so patients can visit their physicians without traveling to a health care facility.
“There have been some loosened or revised guidelines on being able to bill for phone and video visits, which has been helpful,” Shin said. “Obviously, everyone is going to see a drop in the revenue that they are bringing in because of this crisis, but being able to still bill for the phone and video visits can allay some of this concern that the providers have about the revenue they are bringing in.”
Although expanded use of telemedicine allows patients and physicians to use a wider range of communication tools, including telephones with audio and video capabilities, Wong noted this exception may not be extended after the COVID-19 situation. As current HIPAA-compliant telemedicine systems can be complicated to use, Wong believes the use of telemedicine in the future, beyond the COVID-19 pandemic, may be reliant on computer-savvy physicians and patients.
“It is not like two people getting on FaceTime or Skype and talking to each other, although that is what we are trying to do now. But, if we get back to a point where all of a sudden HHS says we have to go back to the HIPAA-compliant systems, then it is going to be tougher,” Wong told Orthopedics Today.
However, in the event telemedicine becomes more accessible after COVID-19, Kelly believes it will have more of an impact on physicians following up with patients rather than with initial visits.
“Nothing can replace the value of the physical examination and patient touch, but..., in terms of once [surgeons] have made a diagnosis and rendered care and a treatment plan, I do think that telemedicine is hugely helpful and convenient,” Kelly said.
Similarly, McKee said telemedicine will not be useful if the physician needs to see an X-ray that the patient does not already have.
“I would be happy enough to look at a hip fracture patient in a nursing home if I had a good X-ray to base my treatment and decision-making on. That would be perfectly fine by me and not have the patient come all the way to the hospital,” McKee said. “Unfortunately, not a lot of places are set up to ... both take the X-ray and to then form some kind of telehealth communication.”
Despite the areas within telemedicine that still need to be ironed out, some institutions have found telemedicine to be helpful so far, according to Harrison, with research done in other medical specialties that show fewer visits to the doctor’s office with the use of telemedicine can lead to increased patient satisfaction.
“I think [telemedicine is] still new and that may be part of it. We are all fascinated with the newness of it at this stage, even from a patient standpoint. But, in the end, I think people will find it will be more convenient for us to use,” Harrison said.
Changed health care landscape
Going forward, the experiences of physicians during the COVID-19 pandemic may fundamentally change the landscape of the health care system and surgical culture, according to McKee. He said, “Before SARS, it was part of the surgical mentality to always come to work, no matter how sick or unwell one felt. After SARS, we recognized this was a major error and we became more accommodating towards absences for sickness, especially when a potentially infectious condition was concerned.”
Kelly believes protocols implemented during the COVID-19 pandemic may help physicians triage patients better, making them more selective regarding which patients need to see a specialist.
“We are taking a second look at maybe we should be doing more triage of patients and saying maybe you should see a family doctor, maybe you should see an internist for this, you do not need to see a specialist for this,” Kelly said. “I think [COVID-19] made us all take a pause and realize and take stock on how efficient we are in providing musculoskeletal care.”
Physician-to-physician contact and communication has also been accelerated through online work groups and chat rooms that provided a platform whereby physicians can share information and knowledge on the latest changes and challenges with COVID-19, according to Kelly.
“It is going to be like a war time acceleration of change. Then, on the other side of this is a freedom and an awareness of great proportions that will help us prevent this from happening again,” Kelly said. “We are going to emerge with so many different resources that will forever change the landscape of medicine. We are going to come out of this better and stronger.”
Meanwhile, sources told Orthopedics Today it is important to listen to and follow the advice of experts during the COVID-19 pandemic.
“Try to stay abreast of the situation and listen to recommendations from your institution and from national authorities,” Shin said. “The obvious is washing your hands and [staying] 6-feet apart ... but I would say try to stay vigilant in terms of protecting yourself and your patients and your staff and hope that this all gets resolved soon.”
As the situation is still fluid, Harrison noted orthopedic surgeons need to also stay flexible and creative from a clinical and business standpoint.
“We have to come up with ways to keep taking care of patients. [Orthopedic surgeons] have to be a little bit creative and then [they] have to challenge the people around [them] to buy into it,” Harrison told Orthopedics Today.
Kelly noted orthopedic surgeons should remember to stay present, look for the blessings, not catastrophize and stay informed but not inundated with information. He added that orthopedic surgeons must think outside of themselves and make the necessary sacrifices to help advance the well-being of patients and the country.
“Think about the most infirm, the most vulnerable. What you can do to make a difference? Believe it or not, it is staying home right now because every time you come in contact with someone who is a carrier, you can transmit it to an elderly patient,” Kelly said. “It is not about us. It is about the common good and that is how we stay resilient.” – by Casey Tingle
- References:
- American College of Surgeons releases new clinical guidance document for elective surgical case triage during COVID-19. Available at: www.facs.org/media/press-releases/2020/covid-clinical-guidance032520. Accessed April 20, 2020.
- CMS releases recommendations on adult elective surgeries, non-essential medical, surgical, and dental procedures during COVID-19 response. Available at: www.cms.gov/newsroom/press-releases/cms-releases-recommendations-adult-elective-surgeries-non-essential-medical-surgical-and-dental. Accessed April 20, 2020.
- COVID-19: Elective case triage guidelines for surgical care. Available at: www.facs.org/covid-19/clinical-guidance/elective-case. Accessed April 20, 2020.
- President Trump expands telehealth benefits for Medicare beneficiaries during COVID-19 outbreak. Available at: www.cms.gov/newsroom/press-releases/president-trump-expands-telehealth-benefits-medicare-beneficiaries-during-covid-19-outbreak. Accessed April 20, 2020.
- WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11 March 2020. Available at: www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020. Accessed April 20, 2020.
- For more information:
- Ryan K. Harrison, MD, can be reached at 543 Taylor Ave., Columbus, OH 43203; email: ryan.harrison@osumc.edu.
- John D. Kelly IV, MD, can be reached at 235 South 33rd St., Philadelphia, PA 19104; email: john.kelly@uphs.upenn.edu.
- Michael D. McKee, MD, FRCS(C), can be reached at 1111 E. McDowell Road, Tower 1, 2nd Fl., #A2-01619, Phoenix, AZ 85006; email: michael.mckee@bannerhealth.com.
- Steven S. Shin, MD, can be reached at 444 S. San Vincente Blvd., Suite 603, Los Angeles, CA 90048; email: steven.shin@cshs.org.
- David A. Wong, MD, MSc, FRCS(C), can be reached at 145 Inverness Dr. East, Englewood, CO 80112; email: david.wong@occ-ortho.com.
Disclosures: Harrison, Kelly, McKee, Shin and Wong report no relevant financial disclosures.
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