Orthopedic surgeons tackle latest surge in COVID-19 cases
With the resurgence in COVID-19 cases across the United States, some states and hospitals are implementing a limit to or postponement of nonessential and elective surgeries similar to the postponement enacted in March 2020.
Postponement of elective surgical procedures started at the Ohio State Wexner Medical Center on the week of Jan. 3, 2022, with weekly reassessments on the status of COVID-19 cases in the area, according to Nicholas Greco, MD.
During the postponement, Greco noted any elective inpatient procedure will be delayed except when the delay of the procedure may cause added harm to the patient or compromise the potential outcome.
“Our exceptions for inpatient procedures, for instance within my field of joint replacement, are patients who have infections that we don’t think it would be best for the patient to wait an extended period of time [and] people who have revision surgery where we think the outcome would be greatly impacted by delaying more than a few weeks. In those special circumstances, we are given exemptions to perform the surgery,” Greco, assistant professor in the department of orthopedic surgery at the Ohio State University School of Medicine, told Healio.
Although inpatient procedures have been postponed, outpatient surgery can still be performed, according to Greco.
“We have enough ambulatory surgery staff, even in the hospital setting, to do the outpatient surgeries, but we’re more depleted on the inpatient nursing staff and that’s why we haven’t been able to do as many inpatient surgeries,” he said.
Long-term protocols
Prior to the postponement, Greco said standard protocols had been in place for both office visits and surgery since the beginning of the pandemic. He noted office visits have been limited to patients only, with visitors only allowed in special circumstances, such as if a patient needs assistance going in and out of the clinic.
“All visitors and patients, obviously, are required to wear masks and then patients aren’t able to come to the outpatient clinic if they’ve been diagnosed with COVID and it’s been within 14 days of the onset of symptoms,” Greco said.
After surgery, Greco noted patients have only been allowed one visitor and no family members have been allowed to stay overnight.
“That’s something that’s been firm except in some isolated circumstances,” Greco said. “We’ve been trying to accommodate patient families by having discounted hotel rates for hotels that are close by to the hospital.”
Surgical load balancing
In some cases, hospital systems were able to narrowly avoid postponement of elective procedures. Northwell Health enacted a surgical load balancing protocol on Jan. 6, 2022, which will stay in place until the last week of January 2022, and involves sharing both the COVID-19 caseload and elective surgery caseload across the 23 hospitals and 13 ASCs in the Northwell health system, according to Nicholas A. Sgaglione, MD.
“Our dedicated ambulatory surgery centers allow us to do certain cases that perhaps would be done in the main operating room, therefore, requiring an overnight stay in the hospital,” Sgaglione, professor and chair of the department of orthopedic surgery at Northwell Health, told Healio. “Now they can be done in the ASCs. So, in addition to load balancing based on the number of hospitals and COVID, we also have the ability to shift cases to different surgery centers.”
To help identify cases that could be performed in an ASC, Sgaglione noted colleagues created a data tracking tool of all surgeries scheduled for January 2022 and prioritized cases based on the urgency of the procedure. He added they were also prepared to cancel some elective surgeries as cases of COVID-19 surged in and around New York, but, in the end, did not have to cancel any cases.
“We came close but based upon our capacity and the ability to balance the inpatient COVID cases, we were able to obviate the need to cancel elective [procedures],” Sgaglione said.
Streamlined protocols
In addition to the number of COVID-19 cases in an area, medical centers also consider surge capacity when deciding whether to postpone elective procedures. Michael McKee, MD, orthopedic surgeon at Banner University Medical Center, said, while the center had episodes when COVID-19 cases were high in the hospital, the center has a “tremendous surge capacity” that has allowed elective procedures to continue in his practice.
“I don’t think [the pandemic] affected us as much as it did in some other places where they were crippled by it,” McKee, professor and chair of the department of orthopedic surgery at the University of Arizona College of Medicine — Phoenix, told Healio. “During the two main peaks, we did have some slowdown of inpatient elective cases, but it wasn’t nearly as bad as I think most places had, especially on the East Coast.”
According to McKee, the focus has been on identifying patients who have COVID-19 prior to surgery. He noted every patient he operates on needs to have a negative COVID-19 test before surgery.
“We have a COVID protocol where we identify COVID patients and if they’re positive, then they have to wait 10 days after the last symptom before they’re allowed back in the hospital for elective procedures,” McKee said.
For emergency procedures, patients are seen in designated COVID preoperative rooms and ORs and the surgeons are equipped with appropriate personal protective equipment for those procedures, according to McKee.
“Our protocols have surely become a lot more streamlined and then, like anything you do, practice makes perfect,” McKee said. “[Doing a COVID case] used to be a real delay and it would slow down your list. Now it’s just another case and we just change rooms, change some gear and forge ahead. It’s more efficient than it was in the beginning of the pandemic when no one was sure what do to and how to do it.”
‘Look in the rearview mirror’
As orthopedic surgeons continue to navigate the COVID-19 pandemic, McKee said it is important to stay flexible and reasonable, and to recognize the strain under which those in the health care profession are working.
“When you’re doing your job, sometimes it’s not apparent to you what a strain the people around you can be under and I think it behooves us to be aware of that and to be more understanding, more patient,” McKee said.
Greco noted orthopedic surgeons should develop a framework for and try to utilize outpatient surgery when it is safe to help with caseloads.
“In our case, we emphasized doing either preoperative telemedicine visits or clinic visits for patients to prep them for outpatient surgery and prep their family members,” Greco said.
While moving forward, orthopedic surgeons need to “continue to look in the rearview mirror” because the COVID-19 pandemic is not over, according to Sgaglione.
“We thought things were over in the summer and fall of 2021 and then these variants showed up and they rapidly proliferated,” Sgaglione said. “So, I would keep my eyes on the rearview mirror.”
When the COVID-19 pandemic does come to an end, McKee said it would be beneficial for members of the health care profession to come together and prepare for the possibility of another pandemic.
“I sincerely hope that at the end of this pandemic that some smart people — and that includes people who run hospitals, people who work in hospitals [and] people who work in the public health system — will sit down in a non-partisan manner, non-political manner, and decide here’s what we did that worked well, here’s what we did that was overkill, here’s when we let the cure become worse than the disease, here’s where we didn’t do enough early on, etc., and just try to come up with some gameplan for the next time this happens because it’s only a matter of time until it does,” McKee said.
References
- AAOS updates guidelines amid COVID-19 pandemic, including resuming elective surgery. https://www.healio.com/news/orthopedics/20200422/aaos-updates-guidelines-during-covid19-pandemic-including-resuming-elective-surgery. Published April 22, 2020. Accessed Jan. 20, 2022.
- American College of Surgeons releases guidance for resuming elective surgery after COVID-19 peaks. https://www.healio.com/news/orthopedics/20200420/american-college-of-surgeons-releases-guidance-for-resuming-elective-surgery-after-covid19-peaks. Published April 20, 2020. Accessed Jan. 20, 2022.
- CMS releases guidance on resuming patient care in areas with low incidence of COVID-19. https://www.healio.com/news/orthopedics/20200421/cms-releases-guidance-on-resuming-patient-care-in-areas-with-low-incidence-of-covid19. Published April 21, 2020. Accessed Jan. 20, 2022.
- COVID data tracker weekly review. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html. Published Jan. 14, 2022. Accessed Jan. 20, 2022.
- Elective orthopedic surgery gradually resumes as some states reopen. https://www.healio.com/news/orthopedics/20200513/elective-orthopedic-surgery-gradually-resumes-as-some-states-reopen. Published May 13, 2020. Accessed Jan. 20, 2022.
- Few states provided guidelines on cancellation of elective procedures during COVID-19. https://www.healio.com/news/orthopedics/20200409/few-states-provided-guidelines-on-cancellation-of-elective-procedures-during-covid19. Published April 9, 2020. Accessed Jan. 20, 2022.
- Governor Hochul announces urgent action to boost hospital capacity and address staffing shortages. https://www.governor.ny.gov/news/governor-hochul-announces-urgent-action-boost-hospital-capacity-and-address-staffing-shortages. Published Nov. 26, 2021. Accessed Jan. 20, 2022.
- Statements from Cleveland Clinic on non-urgent surgeries. https://newsroom.clevelandclinic.org/2021/12/07/statement-from-cleveland-clinic-on-rising-covid-19-cases-in-ohio/. Published Jan. 12, 2022. Accessed Jan. 20, 2022.
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