Surgery During the Surge

Surgical facilities across the country are ramping case volumes back up to pre-pandemic levels even as the coronavirus rages through communities still recovering from the initial wave. The United States has hit 16 million COVID-19 cases and more than 300,000 Americans have died. Hospital ICUs are reaching full capacity and a difficult winter awaits. Still, despite the grim outlook, many surgical professionals say elective procedures should continue in outpatient facilities, where skilled providers spent the better part of last year implementing revamped protocols that allow for safe patient care.

Hospital-based elective cases are on pause in upstate New York because of COVID-19 hospitalization rates, according to Dave Uba, MBA, CEO of Buffalo Surgery Center in Amherst, N.Y. "At this time, surgery centers are not subject to the cessation of elective surgeries," he says. "Some cases can be performed in hospitals if patients are in intractable pain and a delay in surgery has the potential to result in future morbidity and mortality. That being said, the majority of elective hospital-based procedures are being rescheduled."

Procedures that improve the health of patients need to continue.
— Greg Deconciliis, PA-C, CACS

Before the resurgence of the virus in October and November, case volumes at Buffalo Surgery Center had returned to normal levels. Mr. Uba says cases are still significantly backlogged since the nationwide shutdown of elective procedures in April and May, and concedes his surgeons will likely never catch up. "But what we learned during the shutdown is that patients truly did suffer without having access to care," he says. "'Elective surgery' isn't a good description of life-changing procedures that can alleviate or eliminate pain and improve quality of life."

William Berry, MD, MPH, MPA, FACS, loosely defines elective surgery as procedures that can be delayed for six months without causing permanent harm. Knee replacements can be put off — although one could argue debilitating joint pain is reason enough to undergo surgery — but biopsies and treatments of malignancies should go on as planned. "There's evidence that a two-week delay can make a difference in the prognosis of breast cancer patients," points out Dr. Berry, associate director at Ariadne Labs, a joint center for health systems innovation at Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health in Boston.

He's currently working remotely in San Diego, where COVID-19 cases have reached concerning levels. "ICU beds are down to about 13% of capacity," he says. "Resources become stressed once capacity hits less than 10%."

The story is much the same in Massachusetts, where hospitals were filling up with COVID-19 patients in December, prompting the state government to order restrictions on elective procedures. "The main purpose of the order was to preserve inpatient capacity and repurpose hospital staff," says Greg Deconciliis, PA-C, CACS, a physician assistant and administrator at Boston Out-Patient Surgical Suites in Waltham, Mass. "The original order said all ASCs and hospitals should revert to performing only essential cases. ?Fortunately, government leaders decided to curtail inpatient volume and preserve beds while allowing outpatient surgery. Procedures that improve the health of patients need to continue."

Decisions about the status of elective procedures, and deciding where those procedures are performed, will ultimately be made at the local level, says Nancy H. Nielsen, MD, PhD, a healthcare policy expert at the University of Buffalo. "Surgeons are trying to be part of the solution by prioritizing patients who need treatment, because this recent surge could last into the spring," says Dr. Nielsen. "We know the next few months are going to be tough, but surgical providers continue to work hard and will persevere."

Shifts in sites of care

Mr. Uba is surprised by the number of cases still being performed in the main ORs of hospitals that could be done in surgery centers. "There's tremendous opportunity to increase outpatient volume and drive value for patients and payers," he says. "Surgery centers provide a safe, high-quality COVID-friendly option without using up valuable resources from hospitals, which can repurpose their facilities and staff to care for COVID patients during this surge."

Jessica Billig, MD, MSc, a resident physician of plastic surgery at Michigan Medicine in Ann Arbor, says the pandemic has increased awareness of barriers that prevent cases from moving out of acute care facilities and into outpatient ORs. She believes providers are grasping the importance and benefit of same-day surgical care in limiting hospital stays, and says outpatient facilities should look to capture overflow cases or procedures that are moved out of hospitals to free up resources for the treatment of COVID-19 patients.

Surgery centers need to capitalize on the opportunity by maintaining high standards established during the pandemic, according to Mr. Deconciliis. "Many facilities figured out how to survive the shutdown and provide safe, effective care moving forward," he says. "That needs to continue."

By now, says Mr. Deconciliis, hospitals have curtailed their surgical volume and many surgery centers have heard from surgeons looking for ORs to bring their outpatient cases. ?"Facility leaders need to make accommodations for this increased volume," he says, "so patients can get the care they need — even during a pandemic."

Safe patient care should always drive decisions regarding when and where surgery should be performed, points out Mr. Uba. "We've learned a lot about how to perform safe surgery during a pandemic, and our ongoing operations are providing a much-needed relief valve for over-crowded hospitals," he says. "Continuing to schedule cases is better for the health of our patients, and our communities." OSM