POST 22. April 29, 2020. CORONAVIRUS. ..the “ACS released a list of 10 issues that should be addressed before a healthcare organization resumes elective surgeries….”

“A plan that’s needlessly rushed is a plan that will needlessly fail.”- Governor Phil Murphy, New Jersey.

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“Mayo Clinic is furloughing or reducing the hours of about 42 percent of its 70,000 employees across all of its campuses in an attempt to mitigate the financial losses from the COVID-19 pandemic…

“Approximately 30,000 staff from across all Mayo locations will receive reduced hours or some type of furlough, though the duration will vary depending on the work unit,” according to a statement on Wednesday from spokeswoman Ginger Plumbo.

As these will be furloughs, not layoffs, Mayo Clinic will continue to pay for the health care benefits for all of its employees while they are off work…

Doctors will not be furloughed, but will have a 10 percent wage reduction. Doctors who are senior managers will see reductions of 15 percent. Top executives are taking 20 percent reductions.

Some of Mayo Clinic’s medical departments are mostly quiet, so some doctors may be “redeployed where needed most,” according to Mayo.

Hospitals on the Rochester campus are operating at 35 to 40 percent capacity, and surgical volume is at 25 to 30 percent of the level that was expected. About 60 percent of Mayo Clinic’s business comes from elective procedures of the kind that are now on hold.

This is latest step in Mayo Clinic’s financial stabilization strategy to address an anticipated $3 billion loss due to the pandemic forcing a temporary halt in all elective procedures and average medical appointments.” (A)

“Elective surgery does not mean optional surgery. It simply means nonurgent, and what is truly nonurgent is not always so obvious. Gerard Doherty, the chair of the surgery department at Brigham and Women’s Hospital in Boston, which began postponing elective surgeries on Friday, says surgical procedures can fall into one of three categories. About 25 percent of the surgeries performed at his hospital can be delayed without much harm. These might include joint replacements and bariatric surgeries for weight loss. Another 25 percent are for life-threatening emergencies that need to be treated right away: perforated bowels, serious heart problems, bones that have broken through the skin…

All over the country, patients are finding their nonemergency surgical appointments canceled as hospitals prepare for a spike in coronavirus cases. Surgeries for early-stage cancer, joint replacements, epilepsy, and cataracts are all getting pushed back—to ration much-needed personal protective equipment, keep hospital beds open, and to shield patients from the virus. On Friday, the American College of Surgeons recommended that hospitals reschedule elective surgeries as needed. Hospitals in outbreak hot spots such as Seattle, New York, and Boston were the first to act, but more are likely to follow suit.

The last 50 percent are the tricky ones. These cases, Doherty says, have “some potential for harm to delay”; they might include cancer and problems in the blood vessels of the arms and legs. Brigham and Women’s is postponing some of these surgeries now on a case-by-case basis…

Canceling surgical appointments is also meant to limit the number of people circulating through hospitals. Surgeries like Kumm’s, which require a long hospital stay, during which visitors might be coming in and out, Ko said, may be particularly risky from the point of view of spreading the coronavirus. Hospitals around the country are also limiting patients to one adult visitor.” (B)

“In the same week that physicians at the University of California-San Francisco medical center were wiping down and reusing protective equipment like masks and gowns to conserve resources amid a surge of COVID-19 patients, 90 miles away teams of doctors at UC Davis Medical Center were fully suited up performing breast augmentations, hip replacements and other elective procedures that likely could have been postponed.

Across the nation, hospitals, nurses and physicians are sending out desperate pleas for donations of personal protective gear as supplies dwindle in the regions that have emerged as hot spots for the fast-spreading new coronavirus. The Centers for Medicare & Medicaid Services, the Surgeon General and the American College of Surgeons (ACS) have urged hospitals to curtail non-urgent elective procedures to preserve equipment. Washington state, Colorado, Massachusetts, Ohio, Kentucky, New York City and San Francisco have gone further, placing moratoriums on elective surgeries.

Still, in pockets of the country, some hospitals have continued to perform a range of elective procedures, spokespeople confirmed. In Pennsylvania, the University of Pittsburgh Medical Center is continuing to offer elective procedures on a case-by-case basis. In Indiana and Illinois, Franciscan Health will continue some elective surgeries, depending on the availability of protective equipment and the concentration of COVID-19 cases in the area. And in California, Nebraska, Nevada and Wyoming, Banner Health will continue to offer elective procedures in communities that haven’t yet reported cases of COVID-19.

The divergent responses underscore not only the disparities in supply stockpiles from hospital to hospital, but also a lack of coordination — even at a regional level — in getting equipment and medical care where it’s needed…

California offers a prime example of the disparate responses. The state has been an early epicenter for the new coronavirus, with more than 1,000 confirmed cases and nearly two dozen deaths. The San Francisco Bay Area has been hit particularly hard, and emergency room doctors at UCSF this week described dire shortages of personal protective equipment, or PPE. Sutter Health has shut down elective surgeries, as have most other University of California hospitals across the state.

At UC Davis, in contrast, procedures have continued.

“I’ll be clear: There is no reason to cancel elective procedures at this time and doing so would be a disservice to our patients who, for many different reasons, require surgery or other scheduled procedures,” UC Davis Chief Medical Officer Dr. J. Douglas Kirk wrote in an email to employees earlier this week. “We currently have capacity and we have an outstanding supply chain and procurement team, so the UC Davis Medical Center is doing well on supplies, PPE and space utilization.”  (C)

Some hospitals and surgery centers continue to conduct elective surgeries amid the COVID-19 crisis, defying federal requests and state bans seeking to stop the nonessential procedures even as essential medical supplies dwindle.

Medical staff members said the refusal to comply puts them and their families at risk as they are forced to reuse personal protection gear such as face masks. Some said the outsized influence of revenue-generating surgeons is a driving factor….

USA TODAY reported March 21 that hospitals, including UPMC and Virginia Hospital Center in Arlington, allowed some elective surgery. Surgeon General Jerome Adams wrote an op-ed for USA TODAY that day further urging physicians and hospitals to stop. VHC has apparently halted nonemergency procedures.

“As we are in the midst of a whole-of-government effort to fight COVID-19, we need all our health care workforce and more to meet the demands of this challenge,” Adams wrote.  “Every non-urgent case takes precious staff time and energy, straining a workforce already going above and beyond in this fight.”

The American College of Surgeons cited the financial pressure in “ethical guidelines” it released. 

“Health systems, and federal and state governments should begin developing comprehensive solutions to address the financial impact on hospitals, physicians, and other health care providers that result from canceled operations, so that these perceived financial risks do not influence some surgeons to continue to perform elective operations,” the guidelines say…

Facilities allowing nonemergency surgeries include Steward Health Care. The more than 30-hospital chain, which operates in states including Texas and Louisiana, said in a statement that it will “continue to support all scheduled surgeries and procedures, and we will leave the decision on whether it is appropriate to proceed now to our physicians and their patients.” 

Steward said it is “committed to preserving access to scheduled procedure time for as long as possible.”…

Marty Makary, a Johns Hopkins University hospital surgeon and professor, said, “Any entirely elective procedure that uses valuable supplies at this critical time is short-sighted.”

“It is borderline unethical for any U.S. hospital to perform elective surgery if the operation can be delayed three or more months without any health consequences to the patient,” said Makary, author of “The Price We Pay: What Broke American Health Care – and How to Fix It.” (D)

“This week, ACS released guidelines for triaging elective surgery during the pandemic that include seven overarching principles:

1. Although some of the triaging guidelines include recommendations based on a low level of COVID-19 infections, coronavirus cases are expected to surge in the next few weeks and surgical teams are advised to prepare for much higher infection rates when triaging elective surgeries now.

2. Based on surgical judgment and resource availability, patients should get appropriate and timely surgical care.

3. Nonoperative management is advised when it is clinically appropriate for patients.

4. Surgical teams should consider waiting for COVID-19 test results for patients who may be infected.

5. With anticipated staffing shortages, emergency surgical procedures at night should be avoided.

6. Aerosol generating procedures such as intubation and electrocautery of blood increase healthcare worker risk for patients who test COVID-19 positive or are suspected of infection. If aerosol generating procedures are unavoidable, surgical staff should wear full personal protective equipment including an N95 mask or powered, air-purifying respirator designed for operating room use.

7. Although there is insufficient data to make a recommendation for open surgery vs. laparoscopy, surgical teams should pick an approach that reduces operating room time and increases safety for patients and healthcare workers.” (E)

“The ACS bulletin stated the following specific recommendations [11]:

Each hospital, health system, and surgeon should thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations, endoscopies, or other invasive procedures until we have passed the predicted inflection point in the exposure graph and can be confident that our health care infrastructure can support a potentially rapid and overwhelming uptick in critical patient care needs.

Immediately minimize use of essential items needed to care for patients, including but not limited to, ICU beds, personal protective equipment, terminal cleaning supplies, and ventilators. There are many asymptomatic patients who are, nevertheless, shedding virus and are unwittingly exposing other inpatients, outpatients, and health care providers to the risk of contracting COVID-19.” (F)

“What Cleveland Clinic says

The Clinic will determine, based on guidelines set by the Ohio Department of Health, which procedures are non-essential and ones where patients should expect delays.

“This change supports statewide efforts to conserve hospital beds, equipment and supplies while protecting healthcare workers in preparation for a potential surge of patients with COVID-19,” Cleveland Clinic spokeswoman Andrea Pacetti said.

The procedures that will move forward must be life-saving, preserve the function of organs or limbs, reduce the risk of metastasis or progression of a disease or reduce the risk of severe symptoms, according to the Clinic’s guidelines as well as MetroHealth and University Hospitals.

Examples of elective surgeries and other related procedures include,” deferrable bronchoscopy, deferrable upper and lower endoscopies, routine dental procedures, symptomatic problems which are stable, management of benign conditions, cosmetics, primary and revision joint therapy (non-infected), bariatric and elective hernia surgery, and urogynecology,” the Clinic says.

“We continue to adapt to this evolving situation, with the primary goal of keeping our patients and caregivers safe,” the Clinic said in a statement.” (G)

“Healthcare facilities should be able to begin performing elective procedures again if they follow certain protocols, according to guidelines released Sunday by the Centers for Medicare & Medicaid Services (CMS)…

“Every state and local official has to assess the situation on the ground,” she said. “They need to be able to screen patients and healthcare workers for the COVID virus, and we need to make sure that patients feel safe when they come in to seek healthcare services by showing they have the appropriate cleaning in place and that they observe social distancing inside the healthcare facilities.” Verma added that this will be a gradual process in which “healthcare systems across the country need to decide what services should be available. We want to make sure systems are reopening so they can stay open, and doing that in a very measured way.”

The new CMS guidelines specify that “non-COVID-19 care should be offered to patients as clinically appropriate and within a state, locality, or facility that has the resources to provide such care and the ability to quickly respond to a surge in COVID-19 cases, if necessary. Decisions should be consistent with public health information and in collaboration with state public health authorities.”

Once the facility has reopened to patients needing elective procedures, “evaluate the necessity of the care based on clinical needs,” the guidelines state. “Providers should prioritize surgical/procedural care and high-complexity chronic disease management; however, select preventive services may also be highly necessary.”

As for getting the practice ready to accept patients, “Consider establishing Non-COVID Care (NCC) zones that would screen all patients for symptoms of COVID-19, including temperature checks. Staff would be routinely screened as would others who will work in the facility (physicians, nurses, housekeeping, delivery and all people who would enter the area),” according to the guidelines. “Sufficient resources should be available to the facility across phases of care, including PPE [personal protective equipment], healthy workforce, facilities, supplies, testing capacity, and post-acute care, without jeopardizing surge capacity.”

The guidelines also address PPE for patients and staff. “CMS recommends that healthcare providers and staff wear surgical facemasks at all times. Procedures on the mucous membranes including the respiratory tract, with a higher risk of aerosol transmission, should be done with great caution, and staff should utilize appropriate respiratory protection such as N95 masks and face shields. Patients should wear a cloth face covering that can be bought or made at home if they do not already possess surgical masks.” (H)

“Centers for Medicare & Medicaid Services (CMS) Recommendations, Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I

General Considerations

• In coordination with State and local public health officials, evaluate the incidence and trends for COVID-19 in the area where re-starting in-person care is being considered.

• Evaluate the necessity of the care based on clinical needs. Providers should prioritize surgical/procedural care and high-complexity chronic disease management; however, select preventive services may also be highly necessary.

• Consider establishing Non-COVID Care (NCC) zones that would screen all patients for symptoms of COVID-19, including temperature checks. Staff would be routinely screened as would others who will work in the facility (physicians, nurses, housekeeping, delivery and all people who would enter the area).

• Sufficient resources should be available to the facility across phases of care, including PPE, healthy workforce, facilities, supplies, testing capacity, and post-acute care, without jeopardizing surge capacity.” (I)

“Last week, ACS released a list of 10 issues that should be addressed before a healthcare organization resumes elective surgeries that have been delayed. “Evaluating and addressing each of these 10 issues will help facilities to not only optimally provide safe and high-quality surgical patient care, but also to ensure that surgery resumes and doesn’t stop again,” the recommendations say.

The recommendations are highlighted below.

1. KNOW YOUR COMMUNITY’S CORONAVIRUS STATISTICS. The maximum incubation period for the coronavirus is estimated at two weeks. There should be a decrease in incidence of COVID-19 cases for at least two weeks before elective surgery is resumed.  Monitor local COVID-19 statistics such incidence of new cases to detect a resurgence of the virus.  Consider setting a threshold for new cases of COVID-19 that would trigger putting elective surgeries on hold again.

2. KNOW AVAILABILITY OF COVID-19 TESTING AND CRAFT TESTING POLICIES.

Monitor local COVID-19 testing availability and lab result times.

Craft testing policies for patients such as pre-operative testing of patients scheduled for surgery.

Craft testing policies for healthcare workers such as screening and testing guidance.

With false negative test rates as high as 30%, consider establishing retesting policies for patients and healthcare workers.

With fever and lung complications possible in the postoperative period, consider establishing retesting guidelines for symptomatic patients.

3. PERSONAL PROTECTIVE EQUIPMENT.

Before elective surgery is resumed, there should be a stored inventory of PPE or a reliable supply chain for at least 30 days of operations.

PPE policies should be in place for COVID-19 positive patients, persons under investigation, and non-COVID-19 patients, including for high-risk procedures such as intubation.

Consider having all healthcare workers and staff wear appropriate PPE outside the operating room and having all patients wear cloth masks.

4. KNOW KEY HEALTHCARE FACILITY CAPACITIES.

A hospital’s available resources should include peri-anesthesia units, critical care, diagnostic imaging, and lab services.

Consider new sites for elective surgery such as hospital spaces that were converted for COVID-19 care, including outpatient departments.

OR schedules should be set to accommodate a spike of electives surgeries such as performing procedures at night or on weekends.

Make sure there is sufficient capacity for preoperative, intraoperative, postoperative, and post-acute care.

5. SUPPLIES CAPACITY.

Ensure there are adequate levels of surgical supplies and equipment such as implants and anesthesia-sedation medications.

Ensure a supply chain is in place for traditional or new vendors.

Conduct an inventory of existing supplies and check expiration dates.

There should be adequate cleaning supplies, particularly for areas where care is provided to COVID-19 patients and persons under investigation.

6. HEALTHCARE WORKER STAFFING.

There should be adequate multidisciplinary staffing for routine and expanded hours.

Assess coordination of key staff members, including surgeons, anesthesiologists, nurses, and housekeeping.

Have contingencies in place for staff members who test positive for the coronavirus.

Assess the level of stress and fatigue among healthcare workers who have been providing frontline care during surges of COVID-19 patients.

Consider mitigation efforts for workforce shortages such as enlisting retired surgeons to work as first assistants.

7. CREATE GOVERNANCE COMMITTEE.

A governance committee can make real-time decisions for several pivotal issues, including PPE, pandemic assessment, patient backlog, and safety and quality.

The governance committee should be multidisciplinary, including surgeons, anesthesiologists, and nurses.

At least during the elective surgery ramp-up period, the governance committee should meet daily.

8. PATIENT COMMUNICATION.

Consider creating a multidisciplinary committee to manage patient communication.

There are several crucial patient communication topics, including procedure prioritization, coronavirus testing policies, PPE use, and advance directives.

9. PRIORITIZATION OF SURGERY.

Key stakeholders such as surgeons, anesthesiologists, and nurses should participate in ramp-up planning, including the collaborative formation of principles and frameworks for surgery prioritization.

The prioritization process should be adjustable to local, regional, and national epidemiological trends and changes in COVID-19 care. The prioritization process should also take a facility’s resources, priorities, and patient needs into account.

 he prioritization process, principles, and framework should be transparent to hospitals, healthcare workers, and the public. The benefits of transparency include reducing ethical dilemmas.

There are multiple considerations in developing the prioritization process, including a list of canceled and delayed procedures, a strategy for phased opening of ORs, PPE availability, and issues related to increased OR volume.

10. ENSURE SAFETY AND HIGH VALUE IN ALL FIVE PHASES OF SURGICAL CARE.

Optimal care in the preoperative phase includes considering the use of telehealth.

Optimal care in the immediate preoperative phase features reviewing surgery, anesthesia, and nursing checklists for possible revisions related to COVID-19 positive patients and other considerations.

Optimal care in the intraoperative phase includes guidelines for staff during intubation.

Optimal care in the postoperative phase includes adherence to standardized care protocols.

Optimal care in the post discharge phase includes post-acute care facility availability and safety. (J)

“Ohio’s doctors and surgeons have one week to tell the governor what steps they would take to protect patients and conserve personal protective equipment if he were to lift the ban on elective surgeries.

Gov. Mike DeWine said he talked for about two hours Wednesday with medical professionals worried about patients who can’t get help because of the state’s restriction. He told the group to give him a plan that would still minimize the use of personal protective equipment…

Ohio Health Director Dr. Amy Acton halted nonessential surgeries and medical procedures during the coronavirus crisis on March 18. The concern was not that medical personnel and facilities were unsafe, but that regular use might deplete the state’s supply of protective gear, and surgical centers might be needed to house COVID-19 patients.

Neither of those things has happened, said Rep. Nino Vitale, R-Urbana. That’s why he and a growing number of other state legislators want the restrictions on health care providers lifted as soon as possible.

“It is the No. 1 call to our offices — even above ‘I can’t get through to the unemployment number,’” Vitale said.

Dr. Thomas Kramer, a gastroenterologist at the Taylor Station Surgical Center on the Far East Side, said he and many of his colleagues think they should be able to get back to work immediately.

Kramer said he doesn’t doubt the seriousness of the virus but thinks it’s clear that Ohio has avoided a worst-case scenario. The center, he said, has enough personal protective equipment from its usual shipments to operate as normal.

“It’s not making a lot of sense to us as physicians and nurses as things are improving,” Kramer said. “If we’ve got enough equipment, and we’re doing the things they want us to do, and people need the health care … then when are we going to be doing this again?”

Orthopedic surgeon Ian Thompson told the task force that he has patients who probably will need additional surgeries or face worse outcomes because they aren’t getting physical therapy. One female patient got worse because her knee-replacement surgery was put on hold.

“Her knee gave out, and she fell and broke her hip and is now in the hospital,” Thompson said.

A pediatric dentist from Minster in northwestern Ohio said he’s worried about his patients’ teeth shifting because devices such as braces and retainers require frequent checkups.

“The longer that treatment gets delayed, there will be teeth moving in directions unsupervised,” Dr. Phil Slonkosky said. “That’s definitely going to cause some problems.”

DeWine and Acton are the ones with the authority to lift the restriction on nonessential medical care. They’ve been in contact with groups such as the Ohio Hospital Association as well as state legislators.

“I think common sense is going to prevail here,” said Rep. Derek Merrin, R-Monclova. “I expect for there to be a reversal here shortly.”

Merrin acknowledged that short of changing the laws that give Acton the authority to issue such orders, there isn’t a lot that legislators can do to force her hand regarding doctors’ offices and surgical centers. He said hopes that the governor and his team will trust Ohio’s medical professionals to keep their patients and employees safe.

“Health decisions need to be between the physician and the patient … We do not need the state government micromanaging what kind of procedures people will get,” Merrin said. “State government has no role in telling someone if they are going to have a hip replacement or not.”” (K)

“Virginia Governor Ralph Northam is extending several orders he announced earlier in the COVID-19 pandemic, including postponements of elective surgeries and the closure of DMV offices.

Northam announced in a statement on Thursday that the current ban on elective surgeries, which was set to expire on Friday, April 24, is being extended by one week to May 1..

Just a few hours before the governor’s announcement on Thursday, the Virginia Hospital & Healthcare Association sent a public letter to the governor urging his administration to let the elective surgery postponement order expire, saying that hospitals have the capacity to handle both the procedures and COVID-19 cases.

But the governor said the ban on elective surgeries will continue until State Health Commissioner M. Norman Oliver, MD, MA can “evaluate, in conjunction with hospitals and other medical facilities, how to safely ease restrictions on non-essential medical procedures, and the availability of personal protective equipment.”

The VHHA said that Virginia hospitals have already established a framework (which you can review here), for re-opening the health care delivery system in a responsible manner consistent with the Open Up America Again Guidance document recently issued by the White House.

“My top priority is protecting public health, and that includes ensuring that our frontline medical staff have the equipment they need to stay safe as they treat Virginians who are sick,” said Governor Northam. “We have increased our supply of PPE, but before we allow elective surgeries to resume, we must first be assured that the doctors, nurses, and medical staff who are fighting this virus or conducting emergency surgeries have the necessary supplies. We are working with medical facilities on plans to ensure that we can resume elective surgeries safely and responsibly.”

The public health emergency order, Order of Public Health Emergency Two, does not apply to any procedure if the delay would cause harm to a patient. The order also does not apply to outpatient visits in hospital-based clinics, family planning services, or emergency needs.

But the VHHA says the continued postponement of the procedures puts patients with chronic conditions at risk and keeps medical workers furloughed.

Hospitals continue to treat emergency patients and perform essential surgeries, and Northam says “Virginians should feel safe going to hospitals if they are experiencing a medical emergency, such as a heart attack.”” (L)

The American Hospital Association published a road map to resuming elective surgeries on April 17, alongside the American College of Surgeons, American Society of Anesthesiologists and the Association of periOperative Registered Nurses.

The road map details principles and considerations for health care professionals to take into account as they start integrating more elective procedures back into their schedules. Some of the principles include timing for reopening elective surgeries, COVID-19 testing within facilities, adequate Personal Protection Equipment (PPE) supplies, conservation policies for PPE and case prioritization and scheduling…

Resumption of elective surgeries is a part of President Donald Trump’s “Reopening America” plan. “We’re encouraging states around the country to restart elective surgery wherever possible even on a county by county basis,” Vice President Mike Pence said Friday, speaking at Trump’s signing of a $484 billion coronavirus relief package.

As states gauge whether to allow elective surgeries, surgeons and hospitals face the difficult task of balancing patients’ needs with safety and equipment requirements. Postponing elective surgeries has also allowed hospitals to conserve personal protective equipment (PPE) and hospital beds for care involving COVID-19 patients.

“Coronavirus is highly infectious, and if there’s a procedure that would bring people together, just like in a restaurant or an airplane, then avoiding it if it can be avoided is the best practice,” Dr. David Hoyt, executive director of the American College of Surgeons, told NBC News. “You have to balance that with patients that need surgery, but the urgency of it can be triaged, and that’s what was done.”

Some surgeons have also shared concerns about performing elective surgeries on asymptomatic COVID-19 patients, fearful that patient mortality and ICU rates can increase significantly for those with unknown infection at the time of surgery.

Hospitals that resume elective surgeries need to be mindful of maintaining beds and equipment in case there are an uptick of sick patients, Hoyt said. “I think people need to ramp up at some rates, not just do it all overnight.”

Most hospitals have come up with systems to assess the urgency of elective surgeries for their patients…

The University of Chicago hospital published a scoring system this month to aid surgeons in making decisions about elective surgeries. The “Medically Necessary Time-Sensitive (MeNTS) Prioritization” system allows surgeons to assess elective surgeries systematically — evaluating risks for both patients and personnel.

“While these numbers are not meant to be strict cutoffs, as far as if it’s above some number, then you can’t do it and below it, you can, that sort of thing, it at least provides guidance,” Dr. Vivek N. Prachand, professor of surgery and chief quality officer for surgery at University of Chicago, said.

Prachand said that this will provide some guidance and then the threshold of whether to do the surgery can be decided, “not only the score, but the availability of the resources and personnel in the hospital itself, depending on where it’s located, not only geographically but where it’s located along the COVID curve.”.. (M)

“Hospitals are preparing for elective surgeries, which were put on hold because of COVID-19. This comes after Governor Greg Abbott made the announcement Friday to allow the procedures again across Texas.

Doctor Richard Peterson, with the Long School of Medicine at UT Health San Antonio, said the move to allow elective surgeries will be methodically planned.

“Most of the facilities are looking to resume elective surgeries kind of starting next week and it’s going to be a gradual ramp-up,” said Peterson said.

Peterson, who also practices at University Hospital, Foundation Surgical Hospital of San Antonio and CHRISTUS Santa Rosa Health System, said patients undergoing elective surgery are often vulnerable.

“What we don’t want to do is put a patient who isn’t sick, at risk for getting sick, especially with this virus,” Peterson said, “So we are taking extra preventative steps.”

Peterson said because non-emergent surgeries are backed up, there will be a re-introduction process.

“We are going to be careful about how much we are scheduling so we don’t overload and use up all of that protective personal protective equipment,” Peterson told us.

Peterson also said doctors will test every elective surgery patient for COVID-19.

“I think that’s kind of a new change, to ensure that we’re definitely making sure the patients aren’t infected prior to surgery,” Peterson said…

In a statement, Methodist Healthcare’s President and CEO, Allen Harrison, said staff there will follow similar guidelines.

As we continue to monitor the dynamic shifts of the COVID-19 pandemic, Methodist Healthcare has begun to thoughtfully re-introduce elective procedures and surgeries following Governor Abbott’s updated Executive Order on Friday, April 17. Elective procedures are not the equivalent of “optional” procedures that can be delayed indefinitely. Elective procedures are those that can be scheduled. These procedures have been classified within tiers of urgency and acuity, allowing us to prioritize services as we take a measured approach to this transition. While continuing to abide by all state regulations, patients and physicians will see continued, and in some cases enhanced, screening, testing, universal masking and patient cohorting, patient flow procedures, as well as infection prevention protocols in our facilities. As an added precaution, we will conduct universal COVID-19 testing for all elective surgery patients prior to their procedure and will continue with a “no visitor” policy per Health and Human Services guidance.” (N)

“Amid the ongoing COVID-19 pandemic, Governor Andrew M. Cuomo today announced elective outpatient treatments can resume in counties and hospitals without significant risk of COVID-19 surge in the near term. Hospitals will be able to resume performing elective outpatient treatments on April 28, 2020 if the hospital capacity is over 25 percent for the county and if there have been fewer than 10 new hospitalizations of COVID-19 patients in the county over the past 10 days. If a hospital is located in a county eligible to resume elective outpatient treatments, but that hospital has a capacity under 25 percent or has had more than 10 new hospitalizations in the past 10 days, that hospital is not eligible to resume elective surgeries. If a county or hospital that has resumed elective surgery experiences a decrease in hospital capacity below the 25 percent threshold or an increase of 10 or more new hospitalizations of COVID-19 patients, elective surgeries must cease. Further, patients must test negative for COVID-19 prior to any elective outpatient treatment. The State Department of Health will issue guidance on resuming elective surgeries.

Restrictions on elective surgery will remain in place in Bronx, Queens, Rockland, Nassau, Clinton, Yates, Westchester, Albany, Richmond, Schuyler, Kings, Suffolk, New York, Dutchess, Sullivan, Ulster, Erie, Orange and Rensselaer Counties as the state continues to monitor the rate of new COVID-19 infections in the region. 

Governor Cuomo also announced the state will take a regional approach to reopening and will make decisions on which counties and regions to open and when to open them based on the facts and data specific to that area. Lieutenant Governor Kathy Hochul will coordinate Western New York’s public health and reopening strategy, and former Lieutenant Governor Robert Duffy will volunteer as a special advisor to coordinate the Finger Lakes’ public health and reopening strategy.

It is essential that we continue to support hospitals and health care workers in all regions to ensure they have both capacity and supplies to treat COVID patients because this virus is by no means defeated.

“As New York continues to flatten the curve of new COVID-19 infections, we are now ready to lift the restrictions on elective surgeries in regions where hospital capacity and the rate of new infections do not present a significant risk of a surge in new positive cases,” Governor Cuomo said. “It is essential that we continue to support hospitals and health care workers in all regions to ensure they have both capacity and supplies to treat COVID patients because this virus is by no means defeated.”” (O)

“Despite a directive from the governor of Pennsylvania, the state’s biggest hospital system is preparing to ramp up elective surgical procedures — the goal being to reach pre-shutdown surgical capacity within six weeks.

The Post-Gazette has obtained documentation showing that UPMC is gearing up for the move that makes it the only health care system in the region to do so.

A letter to UPMC surgeons dated April 15 from hospital leadership offers guidance to surgeons on how to justify doing such procedures, recommending the use of terms such as “urgent,” “cancer,” “unstable” and “relief from suffering” in reports.

“We have NOT said no to a surgery that the surgeon and patient feels should proceed,” according to the April 15 letter, which was obtained by the Post-Gazette.

UPMC employees told the Post-Gazette in March that they were upset over risks to staff and patient health, and the use of resources that might be needed as the virus spread.

The Pittsburgh-based health system’s push to return to pre-COVID-19 levels of elective surgery comes despite a ban on elective medical procedures issued by the Pennsylvania governor in March, a ban that the state health department said is still in effect.

But a spokesman for the health system, which operates 40 hospitals, said Monday that UPMC believes it can do elective procedures safely and noted that new guidance from the Centers for Medicare and Medicaid Services emphasized flexibility to “allow facilities to provide care for patients needing non-emergent health care.”

If successful, UPMC, which reported $20.6 billion in revenue for 2019, would be among the first health systems in Pennsylvania to restore elective operations.

UPMC was behind other Pittsburgh-area health systems in winding down non-emergency procedures after Gov. Wolf’s March 19 directive, continuing to do them after Allegheny Health Network, Excela Health, Heritage Valley Health System, St. Clair and Washington Health System said they had stopped.

At Allegheny Health Network, the surgical shutdown continues for elective procedures.

“At AHN, we continue to closely monitor the progression of the COVID-19 pandemic in western PA while also communicating regularly with local and state health officials about the safest and most responsible approaches to patient care at this time,” spokesman Dan Laurent said in a statement. “We are preparing appropriately for an organized, phased-in return to normal surgical operations in the coming weeks and will strictly follow CDC and CMS guidelines in order to ensure the safety and well-being of our patients and caregivers when we do.”

To return to pre-shutdown surgical capacity, UPMC is counting on technology that received emergency clearance from the Food and Drug Administration on March 29, which allows COVID-19-contaminated face masks to be sterilized for reuse by doctors and nurses up to 20 times.

Typically, the malleable polyester masks are discarded after wearing once or twice, but nationwide shortages of the protective gear have been reported…

More than 1,300 UPMC employees were briefed on the plans Thursday, where the partnership with Battelle was described as key to the restoration of the non-emergency surgery caseload at UPMC.

On Friday, Gov. Wolf provided a broad outline for reopening the state, but without a timeline or benchmarks that would guide his decision. On Monday, the governor went further, easing restrictions on online car sales and allowing the restart of construction projects statewide May 8. But he stopped well short of ending mitigation efforts.

The Wolf administration does “not feel that today is the day that hospitals should resume these services,” state Department of Health spokesman Nate Wardle said Thursday. “We must take a slow, iterative process as we ease back on our mitigation efforts and not move too quickly.”

He declined to elaborate when contacted Monday. Health officials have warned that ending mitigation efforts too soon could bring a rebound of the disease.

Citing CMS guidance that was issued Sunday, UPMC spokesman Paul Wood said on Monday that the time was right to begin doing elective procedures.

“In the current environment, with proper protection and precautions, we believe that we can soon begin to treat patients who postponed needed treatments and procedures,” he said in a statement.

His comments echoed the new CMS guidance.

“At this time, many areas have a low, or relatively low and stable, incidence of COVID-19 and that it is important to be flexible and allow facilities to provide care for patients needing non-emergent, non-COVID-19 health care,” CMS said. “In addition, as states and localities begin to stabilize, it is important to restart care that is currently being postponed.”

In a conference call with more than 1,300 employees Thursday, UPMC officials said non-emergency operations would be ramped by 10% this week after a case-by-case review, which will include COVID-19 testing of the patient two days before the procedure, according to the person who participated in the briefing but was not at liberty to speak publicly about it. Back surgery for chronic pain and hernia repair are examples of the operations that could start to be scheduled.” (P)

“New Hyde Park, N.Y.-based Northwell Health is giving front-line staff responding to the COVID-19 pandemic a $2,500 lump-sum payment and a week of paid time off.

Physicians, nurses, respiratory therapists and others involved in direct patient care are eligible for the bonus and PTO as are housekeepers, environmental services workers and others. The health system said about 45,000 workers are eligible for the payments and supplemental PTO.” (Q)

WORTH SCANNING

One Rich N.Y. Hospital Got Warren Buffett’s Help. This One Got Duct Tape. https://www.nytimes.com/2020/04/26/nyregion/coronavirus-new-york-university-hospital.html?referringSource=articleShare

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