At Issue: Non-emergency orthopedic surgery in areas with surges in COVID-19 cases
Click Here to Manage Email Alerts
Due to surges in COVID-19 cases reported in Texas, Florida and California, Healio Orthopedics contacted David Ring, MD, PhD; Bryan Hanypsiak, MD; Mark S. Vrahas MD, MHCDS; and Marc E. Umlas, MD, FACS, FAAOS.
We asked these physicians about the status of elective surgery in their areas and whether, given the current situation, their hospitals are still proceeding with non-emergency (elective) orthopedic surgery.
Ring, associate dean for comprehensive care, professor of surgery and psychiatry at Dell Medical School, The University of Texas at Austin, Texas, is Hand & Upper Extremity Section Editor of Orthopedics Today. Hanypsiak is at Physicians Regional Medical Center, in Naples, Florida, and is the Healio Orthopedics Section Editor of Orthopedics Today. Vrahas is professor and chair, department of orthopaedics and Levin/Gordon Distinguished Chair in Orthopaedics in honor of Myles Cohen, MD, at Cedars-Sinai Health System in Los Angeles. Umlas is the Muss Family Chair of Orthopaedics at Mount Sinai Medical Center in Miami Beach, Florida.
David Ring, MD, PhD
Early on in the pandemic, when we restricted all elective surgery to make sure we had enough protective equipment and ventilators, it was interesting to go through the approval process and collectively think through what qualifies as urgent, such as a distal radius fracture healing with malalignment. It is possible to operate on this later and still get a good outcome. For distal biceps rupture and clavicle fracture, nonoperative treatment is a good option.
It was also interesting to note some of the differences between people who chose to put off care and those wanting to move forward, some of them pressuring us to do so. Our sense is the people who were less accommodating tended to be more prone to unhelpful misconceptions and cognitive biases, such as hurt equals harm, in particular.
Many musculoskeletal conditions are accommodated. For instance, the population-based study of Kim and colleagues in 2011 found that only 45% of people with advanced radiographic knee arthritis qualified as having symptomatic knee arthritis. Our group has found that incidental trapeziometacarpal arthrosis is a common incidental finding among older people seeking care for an unrelated condition. As humans experience the expected changes in their body, they have a remarkable ability to accommodate. It is possible that some people will experience that accommodation and decide not to proceed with surgery.
Many musculoskeletal conditions are self-limiting, for instance, enthesopathies such as those of the plantar fascia and the origin of the extensor carpi radialis brevis (commonly known as plantar fasciitis and tennis elbow, respectively). Given time, these will improve without treatment. The pandemic created a space for both thoughtful reflection and patience. Rotator cuff tendinopathy has a similar course, at least in the short term. People with small defects tend feel better over time without treatment even as some of the defects increase in size. It will be interesting to study patterns of accommodation and how they affect rates of surgery as the pandemic evolves. For now, we are essentially back to a normal OR schedule.
The COVID-19 pandemic has brought more firmly into the light inequities in health and care. It has also prompted us to think about the surgeries that are discretionary. The vast majority of orthopedic surgery is discretionary and preference sensitive. Our attention can now turn to providing adequate access to specialty expertise, anticipate common misconceptions and help guide people to the accommodation that is so healthful for many people, and ensure that choices for surgery are based on values (what matters most) and not on misconceptions.
References:
Becker SJ, et al. J Hand Surg Am. 2014; doi:10.1016/j.jhsa.2014.07.009.
Keener JD, et al. J Am Acad Orthop Surg. 2019;doi:10.5435/JAAOS-D-17-00480.
Kim KW, et al. J Bone Joint Surg Am. 2011;doi:10.2106/JBJS.I.01344.
Bryan Hanypsiak, MD
The COVID-19 pandemic has led to difficult decision-making in the health care profession. This has never been more true than in our Florida-based two hospital system. As the number of positive tests in Florida eclipses those in all but four nations, our hospital must strategize to handle patients in our community, as well as overflow patients from other communities whose health care systems have exceeded their capacity. Preparation for a surge of infected patients and conservation of resources must now be routinely balanced with the care of the non-COVID-19 patient whose well-being and livelihood depends on the performance of routine medical care. It is often difficult to draw a discrete line in the sand between emergent and elective cases, particularly in orthopedics. Ligamentous injuries and tendon ruptures may not be considered true emergencies, however, delay in care may lead to life-long consequences for the injured patient. With this in mind, our hospital system has chosen to proceed with elective surgeries for the time being.
Our hospital was closed to elective cases for approximately 6 weeks. During that time, our administration was able to construct a separate treatment area and OR for COVID-19-positive patients. Safety precautions were implemented for patients and staff, and routine visitors were not allowed to enter the hospital. A stout supply chain of personal protective equipment (PPE) was established, along with plans for resource-sharing.
Our rationale for continuing elective surgery is simple. As long as we have an adequate supply of resources, we may continue. These resources include patient beds, ICU beds, ventilators, PPE, operative supplies and healthy staff.
Currently, our hospital is at 50% capacity with ICU bed and ventilator usage less than 50%. We have adequate PPE on hand for both emergency and elective cases and have necessary operative supplies in stock. Our staff was divided into two teams when the pandemic began. The “A” team would take call and cover the emergencies, while the “B” team maintained self-quarantine. This provided our hospital with healthy replacement staff and prevented a single outbreak from reducing our capacity. Any A team staff that became ill would be rotated into quarantine and replaced from the B squad. To date, only a handful of OR staff have tested positive for the [novel] coronavirus and almost all have returned to work following isolation and negative testing.
Finally, preference is given to outpatient procedures which do not tie up beds. Particularly critical is the avoidance of elective cases which might require admission to the ICU for monitoring following the procedure. These procedures should be delayed when the percentage of ventilators in use approaches two-thirds capacity.
With these guidelines, our community-based health care system has found a way to navigate the “first wave” of infected patients while maintaining a broad range of services available to healthy patients who require elective care and while minimizing operative revenue losses. The situation, of course, remains fluid and our staff receives daily COVID-19 updates from administration. At this time, elective surgeries will proceed in our hospitals until we run low on needed resources or are mandated by our governor to halt these procedures.
Mark S. Vrahas, MD
The pandemic has touched every health system. Nevertheless, the consequences and the necessary responses have varied greatly depending on local conditions. The spread of the [novel] coronavirus and local resources, were the most important factors but in many cases, local and national politics also played into decision-making. Like everywhere else, the pandemic has caused unprecedented disruptions at Cedars-Sinai, but there have also been a few resulting positives.
Cedars-Sinai is the largest tertiary academic medical center on the West Coast with 890 licensed beds. The hospital consistently runs at full capacity with a normal daily census of 900 patients. During the conventional flu season, we had to take the unprecedented step of canceling a day of elective surgeries when the census reached 1,000 patients. Our normal capacity concerns mandated an aggressive response with a crisis on the horizon. On March 4, the Los Angeles County Department of Health reported six COVID-19 cases. Cases continued at a trickle until the middle of the month. On the March 14, 11 cases were reported. On the March 15, March 16 and March 17, there were 16, 25 and 50 new cases, respectively, reported and it was clear that community spread was underway. The rapidly developing crisis had already begun in New York, and Los Angeles expected a similar scenario.
On March 18, we made the decision to cancel elective surgeries. We initially struggled to define elective surgeries. Surgeons argued for severe pain to be included as a reason to proceed, but given the subjective nature of pain, it was difficult to use this as a fair criterion. Is back pain worse than hip pain, or foot and ankle pain, or gall bladder pain? Ultimately, we decided that if pain necessitated hospitalization the case could proceed, otherwise only time-sensitive cases, cases in which a delay would affect outcome, could go forward. Cases were adjudicated by the vice chair of surgery with the assistance of the relevant specialty chair. Although we anticipated that surgeons would game the system or aggressively complain, this was not the case. Surgeons stuck to the rules and inappropriate requests were rare. No doubt patients endured additional suffering due to cancelations, but we did not see any effects on outcome except where patients with problems we would have considered time-sensitive presented late because they feared coming to the hospital.
Key to the success was transparency and frequent communication. The well-publicized national shortage of PPE helped surgeons recognize the need for draconian measures. It is not typical for surgeons to worry about hospital operations, but, in this case, they pitched in to help manage the problem.
On the positive side, normally busy surgeons can only sit idle for so long, and they quickly focused their energies on other tasks. Several directed efforts at finishing chapters and papers and at developing new research projects. Others focused efforts on process improvement and developed protocols to be ready when surgeries resumed. We had been slow to implement telemedicine, but the crisis brought on a rapid shift and surgeons found it efficient and plan to incorporate it into their practices in a major way into the future.
Fortunately, Los Angeles never saw the East Coast spike. At the peak of the crisis, Cedars-Sinai had the highest COVID-19 census in Los Angeles, but our peak only reached 140 patients. Through April, case volumes ran at 20% of normal and overall bed utilization was just over 50%. Even though we were still concerned a wave could come, we felt we had enough space and PPE to ramp up surgeries. Initially, we considered only allowing outpatients, but we quickly decided to only avoid cases that may need an ICU stay. We incrementally returned block time to surgeons consistent with their pre-COVID-19 time with the plan to increase time as we followed the course of the pandemic and as surgeons were able to fill their time. We suspected that patients would be reluctant to come to the hospital for surgery, but this was not the case. Patients were anxious to proceed, and surgeons quickly filled their schedules. The full block schedule was resumed Aug. 1, and surgical volumes have returned to 94% of normal.
The shutdown and gradual ramp-up allowed us to change OR processes and culture. Multidisciplinary ramp-up discussions became discussions on how to improve. Moreover, we have returned with greater than our pre-COVID-19 efficiency. We are not out of the woods yet, but we have made the new normal work.
Marc E. Umlas, MD, FACS, FAAOS
Initially, at the beginning of the pandemic, our hospital canceled all elective surgery. They were unsure of the demands which would be placed on the medical center. In May, our hospital began offering elective surgery. All patients receiving elective surgery need to receive a COVID-19 test. No visitors would be permitted during the hospital stay. Orthopedic surgery tends to have few admissions that require ICU stays, especially in my subspecialty of joint replacement. I have been limiting my elective cases to straightforward cases in patients without severe comorbidities. It was surprising how many patients were demanding surgery in these troubled times. The truth of the matter is that all patients with COVID-19 are in a separate building. The surgical tower is made up of pre-tested admissions. Masks and social distancing are enforced. Since we reopened elective procedures, we have not had any adverse incidents because of the pandemic and patient satisfaction has remained high.
Collapse
Read more about
Click Here to Manage Email Alerts