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April 23, 2020

Is it time to restart elective surgeries? Here's how these hospitals are making the call.

Daily Briefing

    In light of recent CMS guidance, some hospitals and medical organizations on Monday took steps to resume non-emergency procedures and surgeries that have been on hold to make room for Covid-19 patients.

    When should you resume elective surgeries? Here's how to know.

    CMS guidance outlines criteria for restarting non-emergency procedures

    CMS in the guidance explains how hospitals in regions experiencing low and stable incidence levels of Covid-19 can begin offering some non-emergency procedures and services. However, the guidance states that health care facilities in areas with a higher number of Covid-19 cases continue to postpone elective surgeries until further notice.

    CMS said hospitals should not restart the services until their state or region has met certain criteria regarding Covid-19 caseloads, including a decline in the rate of Covid-19 diagnoses and cases for at least 14 days. CMS also said hospitals gearing up to offer non-emergency services must be able to test all at-risk health care workers and treat patients without resorting to crisis care strategies.

    The guidance states that hospitals that meet the criteria should coordinate with local and state health officials to confirm the availability of supplies like personal protective equipment (PPE) as well as workforce availability, testing capacity for health care workers and patients, and facility readiness before deciding to gradually transition into offering non-emergency procedures.

    CMS also said the hospitals should screen all patients for Covid-19 symptoms before their non-emergency procedures and establish non-Covid-19 treatment zones for patients who test negative for the virus.

    Hospitals consider restarting emergency procedures

    In response, some hospitals on Monday started assessing their capacity to restart non-emergency surgeries and procedures that have been on hold for about a month, the Washington Post reports.

    Donald Yealy, chair of the department of emergency medicine at the University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center (UPMC), said patients who schedule to come in for a non-emergency procedure will be tested for the new coronavirus two days before they arrive at the hospital. Yealy said that patients who test negative will be separated from Covid-19 patients upon arrival. "There's a lot of necessary care that can be scheduled. There's even some urgent care that has been put off," Yealy said.

    Integris Health and Atlantic Health System also announced plans to test all patients for Covid-19 before their procedures to prevent exposing staff and other patients to the new coronavirus. Atlantic Health added that the system will only perform emergency surgeries on patients who test positive.  

    A spokesperson for Mayo Clinic, which is also preparing to restart endoscopies, colonoscopies, and other diagnostic procedures such as nerve and muscle conduction tests, said the medical center is "taking every precaution to ensure the safety of our patients, staff, and communities, while ensuring the proper resources are available to care for all patients, including staff, personal protective equipment, space and supplies."

    Planning for gradual phase-in

    However, CMS also has stressed that hospitals that choose to restart non-emergency procedures do so gradually to avoid putting more stress on the facility's capacity, resources, and staff. As such, medical professional organizations are establishing guidelines that encourage providers to continue to evaluate procedures based on risk and benefit, the Washington Post reports.  

    Thomas Maddox, chair of the American College of Cardiology's Science and Quality Committee, said hospitals should treat high-risk patients first, even if Covid-19 cases are still high. "I think what we are trying to do is lay out the risk scales, then look at patients, decide where they fit on those risk scales and line them up," he said.

    Some hospitals like Cleveland Clinic are employing a task force to determine how to resume non-emergency surgeries in "phases," according to a representative for the medical center.

    Atlantic Health is separating procedures into five priority levels, with level one indicating a lifesaving procedure, according to hospital officials.

    "We're very focused on the patients [who] may deteriorate in an irreversible way and making sure those are scheduled immediately," said Amy Perry, CEO of Atlantic Health System's hospital division.

    Integris, which resumed outpatient imaging procedures on Monday, has initiated a system-wide algorithm to determine which non-emergency procedures it should offer next, according to Tommy Ibrahim, chief physician executive for the system. 

    Ibrahim said the system hopes to soon offer other procedures, such as cardiac and oncology procedures, but noted that a lack of PPE could be a barrier to offering the services.

    "We won't ramp up if we're redeploying our PPE," he said. "For now we're keeping a very, very tight monitor on that."

    Charles Kahn III, president of the Federation of American Hospitals, also noted that hospitals will have to take safety of both staff and patients into consideration.

    "The trouble is…there is no vaccine," Kahn said. "So when you go back in, you are going to have to be taking all kinds of precautions for hospital workers and for patients" (Sellers et al., Washington Post, 4/20; Morse, Healthcare Finance, 4/20; Bannow, Modern Healthcare, 4/20; Teichert, Modern Healthcare, 4/19).

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