At Issue: Non-emergency orthopedic surgery in areas with surges in COVID-19 cases
Due to surges in COVID-19 cases reported in South Carolina and Arizona, Healio Orthopedics asked Christopher C. Bray, MD, FAOA, and Arash Araghi, DO, MMM, about the status of elective surgery in their areas.
Healio Orthopedics also inquired whether, given the current situation, their hospitals are still proceeding with non-emergency (elective) orthopedic surgery.
Bray is at Prisma Health System, Steadman Hawkins Clinic of the Carolinas in Greenville, South Carolina, and is the assistant program director for the department of orthopedic surgery and a clinical associate professor at the University of South Carolina, School of Medicine – Greenville.
Araghi, of The CORE Institute in Phoenix, specializes in shoulder surgery.
Christopher C. Bray, MD, FAOA
The COVID-19 pandemic has challenged our nation, overwhelmed some of our health care systems and changed how we live and interact on a daily basis. During the month of July, South Carolina experienced a surge in positive cases at rates that brought national attention. During that time, and since, we have been fortunate to be able to proceed with elective orthopedic surgery in our health system. This was important for both the health of our patients and our health care system.
During the initial outbreak of COVID-19 in the United States, South Carolina was relatively sheltered from the virus. Similar to most health care systems, we preemptively began planning for a surge in patients, hospital admissions and the need for ICU beds and ventilators. As orthopedic surgeons, we were initially asked to limit our clinic visits to emergencies, time-sensitive patients and postoperative follow-up patients. Additionally, all elective (non-emergent) cases were held in anticipation of the surge for a 2-week period in April. The American Academy of Orthopedic Surgeons has published guidelines for elective orthopedic surgery which were followed. Surgical procedures were divided into four groups: elective, urgent or somewhat elective, urgent only and emergent. They defined “elective” as those patients with chronic problems whose surgery could certainly be delayed without significant harm to the patient or eventual outcome. Urgent and emergent cases were still allowed.
Our system is fortunate to have multiple hospitals to allocate resources and patients. In anticipation of COVID-19 patients, one of our peripheral hospitals was designated as “the COVID hospital.” We additionally were able to identify other secondary, smaller facilities in the system for overflow, if needed. Bi-weekly meetings occurred with the chief medical officer of ambulatory services with all the necessary division chairs reviewing the trends in positive cases for the state, county and system, bed availability, admissions, ventilators and personal protective equipment (PPE).
At the conclusion of the 2 weeks in April, our system elected to restart elective procedures due to the lack of the previously expected surge in patients and availability of beds, personnel and equipment. In addition, there was already a significant backlog of cases. Financially, the hospital received government funds and was able to continue to provide care despite any loss in revenue. These bi-weekly meetings have continued for ongoing assessment of the hospital system’s resources. Elective orthopedic procedures restarted in late April with temperature and questionnaire screening. Only necessary personnel were allowed to be present for intubation with use of N-95 masks and non-essential staff could enter the room 5 minutes after intubation wearing standard PPE. The room was cleared of non-essential staff for extubation, as well. Elective COVID-19 testing was only performed on a symptomatic basis or for those patients who came from nursing home facilities. All COVID-19 positive patients requiring admission were transferred and sequestered to COVID units within the system separate from outpatient surgery facilities and inpatient elective facilities. No elective procedures were performed on any patient suspected of having the novel coronavirus or having direct or indirect exposure to the virus until the patient was adequately self-quarantined.
In late June and early July, South Carolina experienced a significant increase in COVID-19 positive patients compared to the general U.S. population. The peak was in mid-July with more than 13,000 reported cases in 1 week. We are now down to less than half of that per week and appear to be past the peak. Despite the delayed surge in COVID-19 positive patients in South Carolina, with these procedures we have been able to maintain all elective surgeries at our facilities with the exception of one of the designated secondary COVID-19 hospitals where elective inpatient surgeries were stopped for a 4-week period to ensure appropriate bed availability and surge capacity, if needed. We have continued to have available beds system-wide, PPE, ventilators and personnel without shortage.
As a system, we want to provide elective orthopedic care effectively, safely and responsibly for our patients with chronic, non-life-threatening conditions in order to improve pain or functional impairment, but not at the expense of the health of the patient or the community. Thankfully, many of our patients have still been able to benefit from elective surgery with limited risk and we are still trending in the right direction.
References:
- www.aaos.org/about/covid-19-information-for-our-members/aaos-guidelines-for-elective-surgery/
- www.scdhec.gov/infectious-diseases/viruses/coronavirus-disease-2019-covid-19/sc-demographic-data-covid-19
Arash Araghi, DO, MMM
The COVID-19 pandemic has forced us to re-evaluate many concepts previously taken for granted, such as the use and availability of PPE, and the need to wear a face mask in public. One issue that has now been hotly debated is whether, when and under what guidelines and restrictions should we perform “elective,” “non-urgent” or “non-essential” surgery during this pandemic. In fact, the pandemic has led to a semantic debate about what terminology we should apply to surgeries for conditions that are not an immediate threat to life and limb.
Based on the trajectory of COVID-19 cases in Italy and other countries, the American College of Surgeons (ACS) anticipated constraints on the U.S. health care infrastructure, and on March 13, ACS published its “Recommendations for Management of Elective Surgical Procedures.” On March 18, CMS released its “Non-Emergent, Elective Medical Services, and Treatment Recommendations,” which suggested delaying certain surgeries to preserve PPE, hospital beds and ventilators. This was followed by similar recommendations from the CDC, and subsequently most states implemented some kind of restriction on elective procedures.
In Arizona, Gov. Doug Ducey signed an executive order addressing this issue on March 21. Unlike the ACS and CMS guidance, Ducey’s executive order did some heavy lifting on two important fronts. First, the order defined non-essential or elective surgery. “A non-essential or elective surgery means a surgery that can be delayed without undue risk to the current or future health of a patient,” according to the order. Second, it specified who should decide whether a particular surgery was non-essential or elective, saying “A licensed medical professional shall use their best medical judgment in determining whether a surgery is non-essential or elective.”
At the CORE Institute Specialty Hospital, we developed a policy that was built upon the definitions and the decision-making process set forth in Ducey’s order. We did not stop with that foundation, however. Instead, we incorporated guidance from the CDC, CMS, ACS and AAOS. As a physician-owned specialty orthopedic hospital, our leadership understood the potentially serious adverse consequences that could flow from delaying all non-emergency cases during that time. Therefore, we developed a COVID-19 Elective Surgery Policy to help provide evidence-based guidance to the medical staff during this crisis.
One of the things we did was put together a working group that identified certain clinical conditions for which a delay could cause undue risk or harm to the patient. The working group also developed a scoring system based on individual patient co-morbidities, to risk-stratify patients who were more likely to need prolonged postoperative care and increased resource utilization, as well those who were more likely to have a complicated course if they contracted COVID-19.
Having provided the surgeons with a framework to use for evaluating the risks and benefits of delaying, or proceeding with, a surgery, we also mandated patient education and decision-making by requiring the surgeon to have a COVID-specific consent discussion with the patient, and to document that discussion. Finally, to guard against the possibility that both the surgeon and the patient might overestimate the risks of delaying the surgery, we established a “screen team” to evaluate every case in which the surgeon and the patient decided to proceed with surgery. In a significant number of cases, the screen team advised the surgeon that a scheduled case could be delayed without undue risk to the patient.
This evidence-based methodology and the policy were reviewed with health care attorneys to ensure compliance with Ducey’s order. We also sought and received input from a professor of ethics at a major university.
On April 22, Ducey’s Executive Order 2020-32 outlined the process by which health care facilities could request an exemption from EO 2020-10, and resume elective surgeries as of May 1. The process included implementation of a robust COVID-19 testing program for all health care workers and patients prior to elective surgery; adequate staffing and bed availability; resource availability; and comprehensive screening for anyone entering the facility.
Our request for an exemption was submitted to the Arizona Department of Health. Since May 1, our hospital has been meeting all the requirements for the exemption and surgeons have been safely performing elective surgeries, even throughout another spike in COVID-19 cases in the early summer months. This approach allowed our hospital and physicians to perform elective surgeries safely and help mitigate the impact of delays from COVID-19 on patients scheduled for elective cases.
References:
- https://azgovernor.gov/governor/executive-order/2020-10.
- Jain, A, et al. J Bone Joint Surg Am. 2020;doi:10.2106/JBJS.20.00602.
- www.cms.gov/files/document/cms-non-emergent-elective-medical-recommendations.pdf.
- www.facs.org/covid-19/clinical-guidance/elective-surgery.
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