Surgery resumes with COVID-19 testing, quarantine
Despite precautions, patients may be hesitant about hospital visits in COVID-19 pandemic
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As states began to see a decline in COVID-19 cases in the months following the call for postponement of all elective surgeries, CMS issued new guidance on how to provide essential care in regions with a low and stable incidence of COVID-19.
The new guidelines included the recommendation of a gradual transition with health care providers coordinating with local and state public health officials, according to a press release from CMS. CMS also encouraged health care providers to review the availability of personal protective equipment (PPE) and other supplies, workforce availability, facility readiness and testing capacity when making the decision to resume or increase in-person care.
“Before we start on the journey, before the patient is even scheduled, the plans for the entire episode of care have to be in place,” James R. Holmes, MD, associate chief clinical officer for orthopedics and physical medicine at University of Michigan Medical Group, told Orthopedics Today. “If you start down that journey and everything else is not in place, then it is subject to failure. I think that sometimes gets lost in all of this; it is more than there is an operating room, surgeon, OR time and implants available. It starts well before that and it ends well after that, and each and every point on that continuum has logistical challenges and potential for breaches in safety and efficiency.”
One of the challenges hospitals and surgical centers have had to navigate as elective surgery resumes is catching up with the backlog of cases that were previously postponed, which Holmes said can be difficult for sites that are not accustomed to performing surgery at higher volumes. This may lead to equipment and staffing issues, which may prove challenging to balance surgical efficiency with convenience, he said.
“We are always sensitive that these are patients who have orthopedic problems that we are trying to help. But, when you are maximally efficient, which is what we want to do and what we have been asked to do, your convenience takes a bit of a hit,” Holmes said.
Rescheduled postponed cases
When identifying which orthopedic cases have priority, Robert B. Haimson, MD, said physicians at Sutter Health select patients based on a combination of how long they have been waiting, how significantly an additional delay will affect patients’ outcomes and the ability for the surgeon to perform the surgery.
“For example, if somebody has a big torn meniscus in their knee, no matter how long we wait to do that surgery, for me it is about the same. It is not any more difficult for me to do the surgery if we wait longer,” Haimson, site lead of the orthopedics department at Sutter Group of the Redwoods and orthopedic surgeon at Sutter Santa Rosa Regional Hospital, said. “But it may be that they go from having a meniscus that could have been repaired to now something that has to be trimmed out because they have been on it for an additional 6 weeks or 8 weeks or 10 weeks. It could be that they are creating arthritis in their knee from walking on the torn meniscus, so there is then some permanent damage that could have been avoided by having done it early.”
Sources also noted patient factors, such as age and comorbidities, have to be taken into account when resuming elective surgery and scheduling cases.
Haimson said Sutter Health has used the medically necessary time sensitive procedure score to provide guidance on which cases would be quicker, easier and safer to perform while using less resources.
C. Lowry Barnes, MD, professor and chair of the department of orthopedic surgery at University of Arkansas for Medical Sciences (UAMS), said when surgeons at UAMS Health resumed surgery on April 27, they started with healthier patients who had a low risk of requiring an overnight stay.
“We started back using our state guidelines with outpatient surgeries first and then with elective surgeries that had less than 48-hour stays,” Barnes, who is president of the American Association of Hip and Knee Surgeons, told Orthopedics Today. “We used [American Society of Anesthesiologists] ASA 1 and ASA 2 patients only in the beginning and more younger patients than older patients and then we just had surgeons work through their surgical list.”
However, J. Lawrence Marsh, MD, chair of the department of orthopedics at University of Iowa Hospitals & Clinics, said there are benefits and risks of resuming elective surgery with either healthier or sicker patients.
Performing a lot of smaller, shorter procedures on younger, healthier patients can reduce the amount of PPE the hospital has in stock, while performing longer procedures may not use as much PPE. However, the longer cases would reduce the number of hospital beds available and have higher risks for the patient, Marsh said.
Ultimately, once back doing elective cases, University of Iowa Hospitals & Clinics allowed individual providers to communicate with their patients and decide what their highest priority cases among all postponed patients would be, according to Marsh.
“Even when we were back doing elective cases, we have looked carefully at orthopedic necessity of patients who are older or have pulmonary compromise, have other medical comorbidities, and are continuing to put those types of patients off that probably should still shelter at home,” he said.
COVID-19 testing protocols
After elective surgeries resumed in Illinois on May 11, to protect patients and health care workers from contracting COVID-19, Benjamin G. Domb, MD, medical director at the American Hip Institute in Chicago, said patients are required to undergo COVID-19 testing prior to surgery. However, the timing of testing before surgery differs from state to state and from institution to institution.
The Arkansas Department of Health required testing patients within 48 hours of surgery once elective surgery resumed, according to Barnes.
Elective surgery was allowed to resume in Iowa on April 27, at which time Marsh said physicians at the University of Iowa Hospitals & Clinics required that patients be tested within 24 hours of their surgery.
“Because we were short of N95s and did not have an adequate [supply] to provide them for all anesthesia and all operating room staff for elective cases, all patients have to be tested and they have to be tested here at our facility,” Marsh said.
Illinois required testing 72 hours prior to surgery, according to Domb, who said physicians at American Hip Institute also require patients to quarantine between the time of the test and the procedure.
“Basically, by the time they have their procedure, the patients should have a negative test and should have minimized the risk of exposure to COVID-19 in between when they had the test and when the had the procedure,” Domb said.
Hesitancy among patients
Despite the precautions and protocols established during the COVID-19 pandemic, patients and even some health care providers have reported hesitancy regarding resuming elective surgery while the pandemic is happening, according to Marsh.
“The truth is, I think at multiple levels, there was a natural ... hesitancy to come fully back online,” he said. “That hesitancy was from patients. Not all patients wanted to come to the hospital, whether it was for clinic appointments or surgeries, [and] not all providers wanted to instantly come back fully online.”
To reduce some of this hesitancy, University of Iowa Hospitals & Clinics has provided messaging to patients that says the hospital environment is safer than most other public environments. It has also instituted an elaborate mandated screening process that involves patients being screened over the phone the day before their appointment, and being required to answer questionnaires, wear a mask and have their temperature taken and appointment confirmed when they arrive at the hospital, according to Marsh.
Institutions with multiple facilities, such as Sutter Health, had the opportunity to establish a central location where all patients with symptoms of COVID-19 are sent. That center provides reassurance to patients as they begin the process of rescheduling surgery, according to Haimson.
“[Sutter Health] has office buildings all over the county, but they basically picked one spot where anybody sick was going to go. So, if anybody had a fever, if anybody had a cold, if anybody had a cough, they only went to this one place, which we turned into a respiratory clinic,” Haimson told Orthopedics Today. “The office building where I work, for example, nobody sick has come here for the entire time, and we started screening early on and [used] masks and gloves and extra cleaning. We have been able to reassure people that we have kept this a safe place to come.”
Keep healthy patients from hospitals
Physicians continue to use telehealth as they bring increasingly more patients into hospitals and surgical centers for treatment and surgery, as well as using ASCs when possible to keep healthy patients out of hospitals and away from patients with COVID-19, according to Domb.
“This can help in multiple ways. At first it can help with protecting our patients because they can have surgery in an environment where there are only healthy people, there are no COVID patients, there are small numbers of people so they are not exposed to large numbers of people as they would be in a larger surgical facility,” he said. “Secondly, by using ambulatory surgical facilities, we can alleviate some of the burden from the hospitals that need to be preserving resources for treatment of COVID patients.”
However, as time passes, patients are beginning to self-select whether they want to undergo surgery based on whether their level of discomfort outweighs the perceived risk of going to the hospital, according to Holmes.
Barnes said he has also seen patients who are more willing to go forward with their elective surgery as the number of COVID-19 cases decreases.
“We have seen more patients who want to come into our office and also want to have surgery,” Barnes said. “We have obviously been using much more telemedicine just like everyone, but our patients now are willing to come back to the office and see us.”
Orthopedics in post-COVID-19 era
As the way COVID-19 may impact how orthopedic surgery is performed in the future is still largely unknown, Marsh said hospitals and institutions need to continue to monitor the situation in their area and continue with all safety precautions, including testing patients and wearing masks, for the foreseeable future.
“This is not going to go away for a while. We are probably going to be protecting N95 respirators so clinicians who do have to take care of respiratory patients have them available for a long time, and these things have indirect effects on orthopedic elective surgery,” Marsh told Orthopedics Today. “Patients have to be tested. Patients have to come to an environment where everybody is in hoods and face masks. Those are probably going to be a reality for a long time.”
The regular use of face masks by physicians may mean adjusting and improving physician communication with patients so that PPEs do not have a negative impact on the doctor-patient relationship, Domb said.
“We may need to learn to use more hand gestures, to speak in a more animated intonation and use more facial expressions with our eyes; all in an effort to improve our communication while wearing masks,” he said.
According to Holmes, phone and video calls will become more commonplace for patient visits. At the University of Michigan Medical Group, many patients are provided with telehealth kits postoperatively to be monitored at home instead of being discharged to a skilled nursing facility.
“We have a more robust, comprehensive and involved visiting nurse service, and we are taking care of sicker patients at home through a variety of measures: sending them home with sophisticated telemedicine kits, blood pressure monitors and sometimes even the capability for a blood draw,” Holmes said.
Hospitals and ASCs may also change the setup of their waiting rooms following the COVID-19 pandemic, according to Barnes.
“Rather than having one common waiting room, we may see that we have a series of smaller waiting rooms shared by families and loved ones of the particular patient,” Barnes said.
As patients and providers navigate these changes and adjustments, it is important for surgeons to “stay true to a guiding principle of what is safest and most appropriate for the patient” against the inevitable backdrop of financial and patient pressures to perform more surgeries, Holmes said.
“As long as we keep patients at the center of the discussion with regard to their safe and efficient care, we will always be making the right decision in an environment in which there are competing demands,” Holmes said. “Some of them are logistical, some of them are financial. But, as long as we remember that the patients are at the center of the discussion and their safety is paramount to any decision-making, I think whatever process [surgeons] use will win the day.”
- References:
- CMS issues recommendations to re-open health care systems in areas with low incidence of COVID-19. Available at: www.cms.gov/newsroom/press-releases/cms-issues-recommendations-re-open-health-care-systems-areas-low-incidence-covid-19. Accessed June 10, 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 June 10, 2020.
- For more information:
- C. Lowry Barnes, MD, can be reached at 2 Shackleford W. Blvd., Little Rock, AR 72211; email: liz@uams.edu.
- Benjamin G. Domb, MD, can be reached at 999 E. Touhy, Suite 450, Des Plaines, IL 60018; email: bendombpersonal@drdomb.com.
- Robert B. Haimson, MD, can be reached at 3883 Airway Dr., Suite 165, Santa Rosa, CA 95403; email: boarmaa@sutterhealth.org.
- James R. Holmes, MD, can be reached at 2098 South Main St., Ann Arbor, MI 48103; email: kylieo@med.umich.edu.
- J. Lawrence Marsh, MD, can be reached at 200 Hawkins Dr., Iowa City, IA 52242; email: molly-rossiter@uiowa.edu.
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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 June 10, 2020.
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