Elective Surgery Is Essential

COVID-19

By: Outpatient Surgery Editors

Published: 12/6/2022

COVID-19 isn't going away, but surgical leaders say stopping outpatient procedures poses a greater risk.

Recent spikes in coronavirus infection rates in Florida, Texas, Arizona and California forced some hospitals to pause elective surgeries in order to allocate their resources to the care of COVID-19 patients. The temporary bans on non-emergent cases got the attention of surgical professionals across the country who are still recovering from the nationwide shutdown of elective procedures in March during the initial wave of the pandemic. The shutdown was a devastating blow to sidelined surgical professionals whose livelihoods were put on hold and patients who suddenly learned procedures that would improve their quality of life — or perhaps save it — were deemed optional. The government's decision to suspend non-emergent surgeries was the right call at the time. There were too many unanswered questions about the risks associated with the coronavirus to allow invasive procedures to proceed.

"No one had experience in managing surgical care during a pandemic," says Lisa Rhodes, MPP, chief administrative officer of perioperative services at UC San Diego Health. "There was a lot of fear of the unknown. We wanted to ensure the safety of our staff and patients, but no one knew what that meant."

Elective cases were allowed to resume in May and surgical facilities quickly adapted to new policies calling for COVID-19 testing, daily screenings, universal mask wearing and social distancing. Surgeries have been performed safely for months during the pandemic, causing many surgical leaders to push back against the possibility of future postponements of elective procedures.

"We now have months of experience in how to operate safely in a COVID world," says Ms. Rhodes. "There's a reason why patients decide to have surgery. We're now well positioned to provide the care they need."

The fundamental elements of outpatient surgery — efficient care, same-day discharge, specialized teams who care for relatively healthy patients — make ambulatory care settings ideally suited for the pandemic.

MUTUALLY BENEFICIAL Orthopedic surgeon Steven Beldner, MD, meets with Ashley Cruz before treating nerve damage in her hand at Manhattan Eye, Ear & Throat Hospital in New York City. | Northwell Health

"It's safer to have hips and knees replaced in our hospital or surgery center than it is to go to Walmart," says Richard Berger, MD, a joint replacement specialist at Midwest Orthopaedics at Rush and an assistant professor at Rush University Medical Center in Chicago.

It's no surprise that William Prentice, CEO of the Ambulatory Surgery Center Association (ASCA), believes it's appropriate to keep ambulatory surgery centers open — even as COVID-19 cases are spiking in some states. However, he has data to back up his claim.

He references a survey conducted by the ASC Quality Collaboration, which found that only 16 patients out of more than 84,000 who recently underwent surgery at 709 surgery centers reported being COVID-19 positive within 14 days of surgery. All patients were asymptomatic before and during their procedures, and none of the cases have been definitively linked to the episode of care provided at an ASC, according to Mr. Prentice.

"The assumption at the beginning of this pandemic was that everything had to be shut down, because nobody knew how safe it would be to perform elective surgeries," says Mr. Prentice. "We can now show that we have the ability to keep people safe with the data from cases performed over the last four months at more than 700 facilities. Testing, screening, social distancing, masking and enhanced infection control measures such as increased terminal cleaning have worked."

Cause for concern?

When the number of positive COVID-19 cases started to decrease in May, healthcare workers around the nation breathed a collective sigh of relief. Hospitals and surgery centers cautiously began to reschedule surgeries that were paused when the pandemic hit and dig themselves out of financial distress.

"There are no good medical reasons to cancel elective procedures."
— Richard Berger, MD

After months of sheltering in place, Americans felt it was finally safe to venture out to restaurants, bars and beaches. Within weeks, the virus reared its ugly head again, this time with even more vengeance in certain states, including Florida, California, Texas and Arizona. There were at least 148,692 cases of the coronavirus reported in Arizona as of July 20, according to the New York Times database. However, the number of positive cases was beginning to trend downward after peaking on July 6.

Banner Health System, Arizona's largest healthcare provider, operates a dozen outpatient surgery centers throughout the state. As of late July, the health system has proceeded with elective surgeries. However, Marjorie Bessel, MD, the system's chief clinical officer, says they are currently balancing the need to perform elective surgeries with the need to maintain bed capacities for COVID-19 patients and adequate PPE supplies. "We are postponing non-emergent procedures that require more than a four-hour stay in the post-anesthesia care unit and are likely to result in a hospitalization," she says.

Dr. Bessel believes the risk of delaying elective surgeries is greater than performing them at this time. "It is safe, appropriate and important to continue performing medically necessary elective surgeries that, if delayed, could result in an emergency with far worse outcomes," she states.

Banner Health currently has an adequate supply of PPE, which is monitored on a daily basis. The system is also prioritizing its staff's health and safety by testing each patient before their procedures. When patients arrive for elective surgeries, they undergo a RT-PCR test and antibody testing.

Ultimately, Dr. Bessel says Arizona will see more negative COVID-19 test results and elective cases will be allowed to proceed if the community does its part to flatten the curve. "We must all continue to frequently wash our hands, wear masks, social distance and stay home," she says. "All of these factors help to reduce the spread of COVID-19 and will allow us to continue to provide necessary surgical care."

When COVID-19 cases began spiking in Florida shortly after Memorial Day, facility leaders in the Sunshine State started wondering whether another mandatory statewide pause in elective surgeries was imminent. In late July, a number of organizations were performing only emergent elective procedures and HCA Partners, a prominent hospital chain, temporarily suspended the scheduling of all elective surgeries. But despite a concerning influx in new COVID-19 cases, surgical professionals were adamant about continuing to perform elective procedures.

"Just because surgeries are elective doesn't mean they aren't important," says Beth Davis, CASC, administrator at Physicians Surgical Care Center in Winter Park, Fla. "We can't cut off health benefits for months without dire long-term issues for many people."

Should a second mandatory stoppage of elective procedures occur, Ms. Davis fears there will be grave consequences for healthcare facilities and patients — consequences she believes should be avoided at all costs.

Mr. Prentice is confident that facilities in states that are current COVID-19 hotspots can stay open and operate safely. He doesn't think individual surgery centers will remain open if their PPE supplies are insufficient or if the testing and screening protocols in place are ineffective.

"As long as facilities continue with recommended strategies, there's no reason to postpone surgeries going forward," says Mr. Prentice. "ASCA and medical societies have advised on the necessity of these safety measures, and I'm sure that surgery centers are doing the right thing for their patients and their staff."

Mr. Prentice points out that urgent and emergent procedures were performed at many ASCs during the height of facility closures because some procedures are elective in name only. "That infection risks are lower in outpatient facilities where generally sick people aren't treated is even more pronounced because of the heightened sensitivity of this dangerous virus," he says. "The patient selection processes and histories of low infection rates in surgery centers is more appealing now than ever before. The evidence now shows that ASCs are not increasing the risk of COVID-19 spread. That's the bottom line."

Outpatient, not optional

SAFETY FIRST Heightened hand hygiene protocols are one of the multifaceted precautions facilities have put in place to protect patients and staff during the pandemic. | Northwell Health

Outpatient, not optional

As the pandemic continues, there's a growing realization that postponing elective surgeries is unacceptable. "We need to be really careful about how we define "?elective surgery,' because there are surgeries and procedures that need to be done," says David Shapiro, MD, an anesthesiologist based in Tallahassee, Fla., who has extensive ASC management experience. "The fact that you can schedule elective surgeries in advance doesn't mean they're unnecessary. These people are in pain or have gotten to the point where they can't function normally. You can wait a week or several weeks to do a joint replacement, but it's not something you can postpone indefinitely."

"The fact that you can schedule elective surgeries in advance doesn't mean they're unnecessary."
— David Shapiro, MD

Dr. Berger stopped performing hip and knee replacements for seven weeks during the shutdown, leaving about 250 patients without new joints they desperately needed. "They had adjusted their entire lives to prepare for their surgeries and were devastated at having to postpone them," says Dr. Berger. "Shutting down elective procedures was the appropriate move at the time, but now we need to help get ailing patients back to normal life routines."

Elective surgeries play a critical role in both the short- and long-term health of patients, points out Sandra Jones, MBA, MSM, CPHRM, LHRM, CHCQM, CASC, FHFMA. "Many people have already delayed surgery," says Ms. Jones, who founded Ambulatory Strategies Inc., a management firm in Dade City, Fla. "Restricting their access to surgical care because of potential COVID-19 exposure will cause major damage to their long-term health."

She has firsthand knowledge of the dangers the shutdown caused. One of her family members in their 50s wasn't able to schedule a colonoscopy during the early phase of the pandemic. The family member recently had the procedure done, and cancerous polyps were discovered. "Waiting could've been disastrous," says Ms. Jones. "Here, a timely elective GI procedure was absolutely essential."

While some preventative elective cases such as colonoscopies can literally save lives, others can drastically improve the quality of life for patients. The latter shouldn't be underestimated, according to Ms. Jones. "Quality of life needs to factor into the equation," she says. "How long can patients go without reading or watching TV when they delay cataract surgery? How long can individuals with chronic pain issues go without pain management procedures before their quality of life suffers?"

Of course, there are procedures that can safely be delayed until the current spike abates — especially for high-risk patients with chronic health conditions or weakened immune systems. But how do you determine when elective surgery can proceed and when it should be delayed? Unfortunately, you can't rely on uniform guidance. "Decisions must be made on a case-by-case basis," says Ms. Jones. "Regular communication between patients and their physicians is more important than ever."

Allaying patient fears

The Manhattan Eye, Ear & Throat Hospital, a 17-OR multi-specialty ASC in New York City that performs 17,000 surgeries a year, lost about 95% of its surgical business during the coronavirus shutdown. It re-opened June 8 and is now at about 75% of its former capacity. Reaching that level wasn't as simple as unlocking the door and flipping on the lights.

"Coming to our facilities to work or for surgical care is safer than being out in the community."
— Lisa Rhodes, MPP

"It wasn't like we opened the building and had a line around the block," says Joe Manopella, CEO of the Northwell Health facility. "It took a lot of coordination. We thought we were going to have an unbelievable influx of patients when the state cleared the resumption of elective surgeries, but there were a lot of patients who weren't rescheduling postponed procedures."

The facility had set up a team of providers during the shutdown to rank which 5% to 10% of cases — such as detached retinas, bone fractures and ligament tears — were emergent and needed to be scheduled immediately. Mr. Manopella turned to the same team in June to try to convince worried patients to reschedule their postponed cases.

His staff engaged the surgeons who practice at Manhattan Eye, Ear & Throat and the employees at their offices, giving them frequent updates about enhanced cleaning measures and new testing and screening protocols, and explaining what they should be communicating to patients. Many patients were understandably worried about contracting the coronavirus, so one of the talking points explained how the center wasn't treating COVID-19 patients.

Eventually, Mr. Manopella and his leadership team decided to ask the surgeons themselves to call the patients. "Personal calls from them helped us break through to getting our caseload back on track," says Mr. Manopella.

The surgeons explained that there were no COVID-19 patients at the health system's surgery centers. They told patients that porous furniture had been removed, and the vinyl chairs and sofas that remained were moved apart from each other and cleaned frequently. A staff lounge was converted into an additional waiting area. Patients are tested for COVID-19 before they arrive, and their companions have their temperatures taken before they're allowed in the building.

Dr. Shapiro says effective and constant communication with patients and staff members is more important than ever. "We tell patients everything we're doing to ensure that the likelihood of their exposure is very low," he says. "I've been talking about patient safety all my life, and I don't think this is any different. The goal is still the same — to ensure patients are well taken care of."

Prioritizing safety

As outpatient facility leaders everywhere continue to navigate a rapidly changing and incredibly challenging environment, there are steps they can take to ensure they're performing the safest possible care. "It's an absolute must to document that you're up to date on CDC and infection control guidance regarding COVID-19," says Ms. Jones. "Read the new nationally recognized guidelines, evaluate them, discuss them with your clinical leaders and document everything along the way."

Dr. Shapiro urges surgery facilities to treat everyone in the building as potentially positive for COVID-19. "I'm a realist," he says. "Nothing by itself, including the test, is 100% effective, and due to the nature of this disease, there's a considerable amount of time where a patient is pre-symptomatic, or remains asymptomatic, while they are indeed shedding virus."

The constant uncertainty of who's carrying the virus places an even greater emphasis on ensuring your facility has adequate levels of PPE — and isn't taking needed resources from local providers who are caring for COVID-19 patients.

N95 masks were in short supply during the initial peak of the virus, but Dr. Shapiro says the PPE situation has improved significantly in the past few months as manufacturers and distributors have ramped up their operations. However, he warns to make sure the PPE you acquire is actually approved for use in surgery and suggests continuing your efforts to conserve current supplies.

The safety of both patients and staff is under greater scrutiny due to the pandemic. But both Ms. Davis and Ms. Jones believe outpatient facilities are more than equipped to meet that challenge head-on. Ms. Davis' facility based its current safety protocols on guidance issued by Florida's governor during the shutdown of elective procedures. They prescreen all patients during pre-op phone calls, and require them to come in two days before surgery for a PCR COVID-19 nasal swab, which yields results the day after testing. Positive tests lead to an immediate case cancellation, but those instances have been rare. "We've performed about 1,700 COVID-19 tests, and just five have come back positive," says Ms. Davis. Among her staff members, who are tested daily and required to follow a strict indoor masking policy, there have been zero positive coronavirus test results thus far.

During the shutdown earlier this year, Ms. Rhodes met with clinical leaders to decide what measures needed to be in place to protect patients and staff when elective procedures were allowed to resume. "Safety has been our top priority throughout the entire process," she says.

Clinical leaders at UCSD constantly monitor PPE and supply levels, as well as the community's rate of positive COVID-19 cases, which was approximately 6% in late July. Ms. Rhodes believes her team can operate safely if these measurements are constantly monitored.

Many patients want to undergo surgery at UCSD and are very receptive to learning about the safety measures in place, according to Ms. Rhodes. "Coming to our facilities to work or for surgical care is safer than being out in the community," says Ms. Rhodes. "We operate with an abundance of caution and attention to detail, and take staff and patient safety very seriously. It's what we've always done, and it's what we'll continue to do."

"We know that this pandemic is not going away and that we're seeing spikes in different places," says Mr. Prentice. "The difference between April and August is we have more experience now and know what we can do with screening, testing and social distancing to operate safely. I think policymakers see that."

Says Dr. Berger, "There are no good medical reasons to cancel elective procedures, and I'd never put myself in harm's way. I'm performing surgery because I know it's safe to do so and because I want to help my patients." OSM

Elective Surgery Is Essential