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    Hospitals cautiously resume some surgeries

    Restarting surgical procedures in the midst of a pandemic has been challenging, with the need to prioritize a backlog of cases while maintaining adequate supplies of PPE and ICU beds. The hardest part? Convincing a wary public to return to the hospital.

    A patient in a mask is being cared for in the emergency room by two doctors in PPE

    The great paradox of COVID-19 for the U.S. health care system has been the devastating financial toll the pandemic has taken on hospitals even as they are called upon to care for an increasing number of patients with severe COVID-19-related disease. More than 250 hospitals have laid off or furloughed staff, and a recent analysis predicted that U.S. hospitals would lose approximately $200 billion between March and June, with $161 billion in losses due to canceled surgeries, delayed outpatient procedures and services, and reduced emergency department visits.

    As states begin to reopen, one of the first actions many governors have taken is to allow hospitals to resume elective surgeries and procedures. But as academic medical centers begin to “reopen,” many are finding that restarting in-person care in the midst of a pandemic poses unique challenges.

    • How do you determine which patients’ procedures take priority over others? For instance, which urgent cases safely delayed during the pandemic should take priority, and once those are done, which elective procedures can be safely performed?
    • How do you ensure the safety of the patients entering your system as well as the safety of your staff?
    • How do you track and manage your supply of personal protective equipment (PPE)?
    • How do you begin to perform these surgeries while remaining prepared to handle a surge in COVID-19 patients as states begin to relax stay-at-home orders?
    • And, equally important, how do you convince patients that it’s safe to return to the operating room or the emergency department, when for the last two months you’ve told them to stay away?

    “We did a great job in educating the public on not coming to the ER unless it was truly an emergency. We said, ‘For something that isn’t urgent or essential, don’t come in,’” says Patrice Weiss, MD, chief medical officer of Carilion Roanoke Memorial Hospital in Roanoke, Virginia. “Now we have to reeducate the public on what we’re doing to make sure that our offices and our hospital are safe.”

    For all those reasons, the move to reopen hospitals has been intentionally deliberate, with multiple measures put in place to address a backlog of cases while ensuring the safety of patients and staff, even while preparing for a potential second wave of COVID-19.

    “We’re keeping our finger on the pulse of what’s happening because we may have to shift back to COVID-19 mode,” says Sally Houston, MD, executive vice president and chief medical officer at Tampa General Hospital (TGH), a 1,000-bed academic medical center that started scheduling elective surgeries the week of May 11. “If we get lucky and the virus decides to take a summer vacation, we may catch up before the fall. If it doesn’t, we may have to pivot back.”

    Deciding when and how to resume surgeries

    Many hospitals have put in place strict protocols for when and how to restart surgical procedures. At West Virginia University (WVU) Medicine, a four-phase reopening plan takes into account the burden of local disease, which in the case of West Virginia never did reach the rate of surrounding states like Ohio, Virginia, and Maryland, says Stephen Hoffmann, MD, vice president of clinical integration who was tapped in early March to lead WVU’s 18-hospital response to the pandemic.

    “Each phase requires seven days of stability in our rate of COVID and stability in our availability of PPE and number of beds,” Hoffmann says. “With each change in phase, there’s probably a 10% to 15% jump in the number of procedures, ambulatory visits, and ancillary services we’re providing.”

    Because most hospitals have a tremendous backlog of cases — the University of California, Irvine (UCI) Health tallied up 1,000 procedures that were postponed between mid-March and the first week in May, says UCI Health Chief Medical Officer William Wilson, MD — many have also established multidisciplinary committees within their hospitals to look at that backlog of cases and decide which should be prioritized.

    At TGH, a group of physicians met throughout the pandemic to “review cases and decide which cases should move forward and which should wait,” says Houston. Throughout this first wave of the pandemic, the hospital has operated at about 50% capacity, with a number of beds reserved for a potential surge of COVID-19 cases and other emergencies.

    Similarly, at WVU Medicine, a committee consisting of representatives from every surgical department meets daily to review every case. Those with significant heart and valve and blood vessel diseases have been prioritized in Phase 1, as have some cancer patients, Hoffmann says. “Every physician feels like their case is important, but we have to look at the big picture,” he says. “It’s a little bit of numbers but then also some decision-making among physicians and administrative staff.”

    The American College of Surgeons (ACS) has issued broad guidelines to help hospitals and surgeons determine how to triage patients for elective surgery, with separate guidelines for cancer patients. “Cancer is one of those things that once you have the diagnosis, the urgency would appear to be immediate, but that’s not always true,” says ACS Executive Director David Hoyt, MD. “We wanted to provide a science-based approach to triaging patients” during the acute and recovery phases of different types of cancer. So far, the ACS has issued detailed guidance on how to prioritize surgeries for patients with breast cancer, colorectal cancer, kidney cancer, melanoma, pancreatic cancer, prostate cancer, soft tissue sarcoma, testicular cancer, thoracic malignancies, and bladder cancer.

    “Surgeons are raring to get back to doing surgeries; it’s what they do,” says Hoyt. “But they want to do it correctly.”

    A team of six surgeons from the University of Chicago Medicine has also developed an online calculator for hospitals to use in gauging their capacity to perform surgeries while still maintaining capacity for a surge. Called the Medically Necessary Time-Sensitive Prioritization, the calculator takes into account 21 factors such as outcome, use of resources, and risk of viral transmission to providers and patients.

    Keeping patients and staff safe

    As hospitals begin to resume surgeries, part of the challenge is ensuring the safety of patients and staff. At UCI Health, all patients undergoing elective surgeries must undergo preoperative testing for COVID-19, Wilson says. That requirement included opening a drive-through testing site on Sunday so that patients having procedures on Monday could be tested in time. UCI Health has several testing instruments, including ones that can provide results in 30-45 minutes, two to three hours, and four to eight hours, respectively. “If anyone comes into the trauma bay, we treat them presumptively as if they have COVID. For all other patients, they get tested” using one of the available testing instruments, Wilson says.

    At TGH, administrators decided two weeks ago to test everyone in the hospital — about 600 patients. “We kept hearing about asymptomatic patients, so we decided to test everybody,” Houston says. They did not find a single patient with COVID-19 who was not already being treated for the disease. To maintain that environment, Tampa is now testing everyone who comes into the hospital via the emergency department or the operating room — up to 850 tests per day.

    At Carilion, staff are reaching out to patients whose procedures have been delayed and asking them to self-isolate for two days and then get tested for COVID-19 three days before surgery, with results usually coming back within two days. “Basically, we are asking patients to commit to five days of self-isolation before surgery,” Weiss says. “We’ve also become basically a visitor-free hospital, with no visitors allowed unless it’s a hardship for the patient. There are no more waiting rooms; we are asking families to drop their loved ones off and wait in the car or go home.”

    For patients who must stay overnight in the hospital, such as a woman having a baby, they are allowed one visitor — “not one visitor at a time but one visitor a day,” Weiss says. Exceptions are also made for end-of-life and pediatric patients.

    As surgeries and other procedures ramp up, hospitals are keeping a close eye on still-scarce supplies of PPE. “Our senior VP of materials management has a daily count for us,” Weiss says. “Three days a week, we have our OR surgery update and a discussion. Are we short on any PPE? How’s our testing? If we got low and couldn’t get a supply in, we’d need to pull back.”

    At the University of Mississippi Medical Center (UMMC), Vice Chancellor and Dean LouAnn Woodward, MD, monitors the PPE supply report daily. “I don’t feel confident that I can stop watching it,” she confesses. “We are very careful in the use of the N95 and other types of masks. And we’re starting to irradiate masks, but we’re not even counting those in our daily count.”

    Even still, with elective surgeries restarting and the need for every health care provider to be masked, making sure the PPE supply chain is properly maintained is critical, she says. A blue jean factory in the state has started making fabric masks and two local distilleries are making hand sanitizer, which has helped.

    All preop patients are tested before their surgeries and many other patients entering the health system are tested as well, particularly if they’re symptomatic, Woodward says. “Everybody wants to get back to what they were doing. I had one surgeon say, ‘I haven’t operated in a month; I’m about to lose my mind.’ But as we start to loosen up our restrictions, we are carefully monitoring the situation so we can react if needed.”

    At WVU Medicine, all 18 hospitals within the system are sharing tests and PPE, with the understanding that if one hospital becomes overwhelmed, the others need to pull back to allow for a potential surge. “It’s a continual process of evaluation and analysis and redistribution,” says Hoffmann. “That’s going to go on for the next month or two.”

    Convincing patients to come back

    While hospitals are being diligent about when and how to resume surgeries safely, many are nonetheless confronting a challenge not seen before COVID-19: The unwillingness of patients to come to the hospital, even when they’re quite ill.

    Throughout the pandemic, doctors have been sounding the alarm about the dearth of patients suffering from heart attacks and other serious emergencies in their hospitals. Renowned Yale cardiologist Harlan Krumholz, MD, detailed the phenomenon in a New York Times opinion piece in early April, Where Have All the Heart Attacks Gone?If fear of the pandemic leads people to delay or avoid care, then the death rate will extend far beyond those directly infected by the virus,” he wrote. “Time to treatment dictates the outcomes for people with heart attacks and strokes. These deaths may not be labeled Covid-19 deaths, but surely, they are collateral damage.”

    In West Virginia, hospital occupancy was down to 50% or 55% of the normal rates until about two weeks ago, when it bumped up on its own to 70%, Hoffmann says. “I think people in West Virginia just toughed things out until they couldn’t any longer. Maybe they had heart failure or diabetes that was starting to get a little out of control. So maybe we’ll get a bolus of those medically sick patients and that will level out.”

    Even as critically ill patients return to the hospital of necessity, not all patients are as eager to reschedule their elective procedures. At Carilion, 40% of gynecologic oncology patients called by staff last week said they wanted to wait a bit before coming in, Weiss said. “A newly diagnosed cancer is different, but for those with post-op follow-ups or ongoing care or post-cancer surgery, they are somewhat hesitant. We’re working hard to make sure patients know that it’s safe to come in.”

    Weiss and her colleagues have given multiple interviews to reporters with the Roanoke Times and have educated office staff to ensure they are familiar with all the processes the hospital has put into place to ensure patient safety.

    But hospital executives know they have a tough road ahead, even as they stay flexible to handle any upcoming surge in COVID-19 patients. “We are one of those academic medical centers that for several years has run at full capacity and many days we were oversubscribed,” says UMMC’s Woodward. “A big topic of conversation internally is, ‘How are we going to reset that capacity threshold?’ Initially, we need to set it lower to handle an unexpected surge. So, we are working through our backlog while also maintaining some flexibility. What we call normal will be very different than it was a year ago.”