Elective orthopedic surgery gradually resumes as some states reopen
As some states begin to reopen amid the COVID-19 pandemic, organizations such as CMS, the American Hospital Association, the American College of Surgeons and the American Academy of Orthopaedic Surgeons have released new guidance on when and how hospitals and surgical facilities should resume elective surgical cases.
Across these organizations, the provided guidance stresses the importance of working with local and state public health officials to ensure the safety of patients, health care personnel and staff. This includes reviewing the availability of personal protective equipment and other supplies, workforce availability, facility readiness and testing capacity, according to guidance from CMS.
“During the course of the COVID-19 outbreak, orthopedic surgeons have continued to provide critical emergency surgical care to patients both safely and effectively. Others have postponed elective surgeries in compliance with federal guidelines and are experiencing mounting financial impact,” Joseph A. Bosco III, MD, FAAOS, president of the AAOS, told Healio Orthopedics. “Now as the nation is gearing up to offer non-emergency services again, the AAOS suggests that surgeons continue to look to our guiding principles that address staff and patient safety, testing and risk stratification. Decisions should be locally based, as factors such as COVID-19 prevalence community needs and resource availability vary by locale.”
Resumed surgery in a graduated fashion
In Arkansas and Michigan, some orthopedic surgeons have resumed certain elective procedures in a graduated fashion as cases of COVID-19 have reportedly tapered off in some areas of those states.
Despite having eight operating rooms in its outpatient center, C. Lowry Barnes, MD, professor and chair of the department of orthopedic surgery at the University of Arkansas for Medical Sciences, noted the center began by using four of the operating rooms to manage appropriate social distancing between the preoperative and postoperative areas.
“For many hospitals and surgery centers, the biggest challenge is appropriate social distancing before and after surgery,” Barnes told Healio Orthopedics. “That is why we are only using four of our rooms to start to make sure that we can appropriately social distance. We are not using waiting rooms, so our patients will check in at the street level, be met there and then go straight to their preoperative area rather than using a waiting room.”
According to Barnes, he and his colleagues are beginning with 20 cases per day, Monday through Saturday, and are only scheduling patients with an American Society of Anesthesiologist grade of 1 or 2. He added they are also required to test patients for COVID-19 48 hours before surgery, which is something Barnes said orthopedic surgeons and hospitals need to consider prior to resuming elective surgery.
“This is testing for the virus, not for the antibody, and the time guidelines can be difficult,” Barnes said. “For us, we have to have testing within 48 hours. That means that our Monday and Tuesday patients are getting tested on Saturday and Sunday. They have to set up a process for how they can do that.”
At the University of Michigan Medical Group, in coordination with a large group consisting of hospital leadership, critical stakeholders, public health officials and medical professionals, James R. Holmes, MD, said the medical group first decided to keep surgical cases at a location outside of the main hospital and assessed its resources.
“Many OR nurses were redeployed to the hospital. Many surgical techs were redeployed as safety officers in the ICUs. Some of the sterilization equipment was redeployed to repurpose masks,” Holmes, associate chief clinical officer for orthopedics and physical medicine at the University of Michigan Medical Group, told Healio Orthopedics. “All of those resources, human and otherwise, need to be accounted for and marshalled in order to resume.”
Holmes also noted the group created a four-tiered classification approach for prioritizing cases across all surgical specialties, not just orthopedics, which takes urgency of the procedure into account as well as patient comorbidities.
“There is a multidisciplinary group that came up with a scoring system that has worked well in terms of a number score based on urgency, based on comorbidities, based on a lot of different things,” Holmes said.
Although hospitals and orthopedic practices may be experiencing financial pressures and pressure from patients to resume elective surgery as soon as possible, Holmes said it is important to follow a guiding principle of what is safest and most appropriate for the patient.
“Having a well-thought-out plan that maximizes safety for both patients and providers ... is easy to articulate and sometimes hard to enact, but that is my best advice,” Holmes said. – by Casey Tingle
Disclosures: Barnes, Bosco and Holmes report no relevant financial disclosures.