Resuming Elective Surgeries: What to Expect

After weeks of shutdown due to the COVID-19 pandemic, several states have given the green light to begin resuming elective surgeries, which will bring health care professionals back to work and generate income for hospitals and health systems.

“The immediate advantage to getting back to elective surgery is to restore the normal treatment of patients, so they can get back to their lives,” said Tyler Hughes, MD, FACS, an officer of the American College of Surgeons (ACS) and a clinical professor of surgery at the University of Kansas School of Medicine in Salina.

“It’s hard for a surgeon to stand by, seemingly doing nothing, when they have these skills and are ready and willing to apply them,” Hughes continued. “And when elective surgeries stop, cash flow stops for everyone in the system. Resumption of cash flow is how we are going to dig our way out of the economic hole this pandemic has caused.” 

Regional variations 

Resuming elective procedures will depend on the location, with some coronavirus hot zones continuing to delay non-urgent surgeries. However, in regions with fewer COVID-19 cases, resuming such care will serve both patients and physicians.

“It seems like the right time for a lot of communities to begin this,” said Mary Dale Peterson, MD, president of the American Society of Anesthesiologists.

“We have a lot of anesthesiologists sitting on the sidelines,” Peterson said. 

Peterson estimates about half of the anesthesiologist workforce has been furloughed and are not getting paid. Resuming elective surgeries will get these physicians back to work. Another group are working in hot zones to help with intubations, line placements and ventilator management.

Similarly, surgeons may be home or working locum tenens assignments, Hughes said. Some have redeployed to the New York metro area, which is the hardest-hit area in the country, and are incredibly busy. Hospitals have laid off clinicians, and some have accepted assignments elsewhere.

Resuming elective procedures also will bring back to work certified registered nurse anesthetists (CRNAs), according to the American Association of Nurse Anesthetists (AANA), which supports “lifting the prohibition of elective, non-urgent surgical procedures.” 

Mitigation of risk 

“The first challenge is knowing when it’s safe to return to the operating room,” Hughes said. “Most of the time, the risks to the patients and ourselves are well defined. But this is a different scenario.”

Hughes said it’s hard to know who is safe to operate on, and not knowing can put the entire surgical team at risk for a potentially fatal disease. Testing pre-op might not give the answer. A rapid PCR test is more complex than routine blood work and results may be wrong.

“There needs to be a discussion with all members of the surgical and perioperative teams,” Hughes said. “Everybody is at risk, and if we make poor decisions, we could have a local outbreak.”

Those discussions should include criteria about what surgeries to perform, and in what order. Medical ethics call for treating the sickest patients first.

“Money cannot be the ultimate decider of the fate of Americans’ lives,” said Hughes, adding that “the economic pressure will be enormous.”

The ACS guidelines for resuming elective surgeries recommend a multidisciplinary governance structure that assures fairness before opening the doors. The rate of startup also needs consideration.

Hughes also suggested starting small and monitoring what happens before taking on more cases. Plan beforehand, prior to an outbreak.

Care for patients 

Some states have been quite strict about elective cases since the beginning of the COVID-19 pandemic, Peterson said. For instance, in Texas, where she practices, the definition of surgeries that could be performed were those procedures that would prevent permanent harm. It created a criminal penalty to operate on anyone else, including cancer surgeries.

“It’s not an emergency, like it has to be done today, but it should be done in a timely manner,” Peterson said. “Now that we are more than a month into this, we have a backload of those cases. We can now get these patients in and get those surgeries done.”

Some people, she explained, have been going without care due to the coronavirus and their health has deteriorated because of it, for example a patient presenting at the emergency department with a ruptured appendix.

Peterson expects to be “living in a COVID world until we have a vaccine, so what we are looking at is a year or a year-and-a-half.” Dealing with that reality will require creating a safe environment for health care workers and patients, including the use of personal protective equipment and continued social distancing.

Professional roadmaps 

The Centers for Medicare & Medicaid Services (CMS) released guidelines for resuming elective procedures. It advises setting up separate COVID-19 and non-COVID-19 units and assigning staff to one or the other, with no rotation. States also have set guidelines for performing non-urgent surgeries.

The American College of Surgeons, American Society of Anesthesiologists, Association of periOperative Registered Nurses, and the American Hospital Association issued a joint statement entitled Roadmap to Resuming Elective Surgery After COVID-19 Pandemic. It warns about a significant pent-up demand for resuming elective procedures.

The recommendations in the Roadmap include waiting to start performing non-urgent surgeries until a 14-day sustained decrease in new COVID-19 cases in their community, and ensuring the facility has enough beds, personal protective equipment, ventilators, medications, supplies and staff. It suggests testing patients and staff for the coronavirus. Priorities should be given to cancer surgeries, transplants, cardiac procedures and trauma cases.

AANA also has released a position statement on resuming elective surgeries. In addition to the recommendations of the CMS and joint statement, AANA declared individual providers are entitled to safe working conditions, to receive recognition for their contributions, and to retain the temporary removal of barriers to their scope of practice.

“I believe things will always turn out well if you work hard enough,” said Hughes, expressing his opinion. “This is going to turn out OK. It will be painful, and there will be trouble. But looking out a year from now, I see no reason to be apocalyptic.”

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