Hospitals prioritize cases, assess supplies before resuming procedures

An article in Modern Healthcare

Hospitals prioritize cases, assess supplies before resuming procedures

Tara Bannow , Modern Healthcare


Hospitals whose COVID-19 peaks are behind them are eagerly forming or mobilizing plans to resume elective surgeries, which have largely ceased since mid-March to preserve capacity for coronavirus patients.

Providers, now armed with guidelines from CMS and leading professional organizations, are trying to determine how to phase procedures back in safely. But there's an urgency to the process—countless hospitals and physician groups are bleeding money while they forgo profitable surgeries to treat expensive COVID-19 patients.

"The financial impact has been astronomical," said Dr. Tommy Ibrahim, chief physician executive at Oklahoma City-based Integris Health. He estimates the system has lost $25 million this month.

The CMS on Sunday unveiled the first of a three-phase plan to resume elective surgeries, but the agency said hospitals shouldn't start the process until their states or regions have met so-called gating criteria announced April 16. That includes declines in the rate of positive COVID-19 tests or cases for at least 14 days. It also says hospitals must be able to treat all patients without resorting to crisis care and must have robust testing in place for at-risk healthcare workers.

Joint guidelines released Friday by the American Hospital Association, the American College of Surgeons and other groups also featured the 14-day rule. Like CMS, the groups encouraged providers to first get clearance from state and local governments before resuming procedures.

Both sets of guidelines encourage providers to take careful inventory of their workforce, testing supplies, personal protective equipment and facilities to assess their readiness to restart procedures. Perhaps acknowledging widespread shortages of PPE and tests, neither set of guidelines explicitly directs providers to test every patient for COVID-19 before performing procedures on them. The CMS guidance says all patients should be screened for symptoms, including temperature checks, and providers should establish non-COVID zones and assign staff to work exclusively in those areas.

However, several providers said they plan to test all patients for COVID-19 beforehand. Morristown, N.J.-based Atlantic Health System is one of them. Amy Perry, CEO of Atlantic's hospital division, also said the system will only perform surgery on COVID-19-positive patients if it's life-saving procedure.

The same is true for Integris. Testing is crucial because surgeons, anesthesiologists and operating room staff could potentially be exposed to an infected patient, Ibrahim said.

"We are absolutely going to be testing those patients," he said.

Escondido, Calif.-based Palomar Health also plans to test all patients prior to surgeries, as physicians and other caregivers have expressed concern for their families' safety, said Dr. Omar Khawaja, the system's chief medical officer. But that could present a hold-up for the system: Palomar currently doesn't have enough tests and test supplies for all patients. The CMS guidance recommends designating separate areas for COVID-19 patients as well as COVID-19-free zones, and Khawaja said Palomar can't do that currently.

On the other hand, Palomar's two hospitals, with about 400 beds total, currently only have 10 to 15 COVID-19 patients, Khawaja said. And there are lots of people in the community with intractable pain whose conditions have worsened in recent weeks and haven't been able to schedule procedures.

"The great thing is we're not seeing it, but we've got a lot of open beds and a lot of need in our community that we're not meeting right now," he said.

Atlantic Health is ranking procedures on five priority levels. The system is currently performing lifesaving procedures, level 1, and procedures considered urgent, such as the removal of malignant tumors, or level 2.

"We're very focused on the patients that may deteriorate in an irreversible way and making sure those are scheduled immediately," Perry said.

All procedures will continue to be done in hospitals, as opposed to ambulatory surgery centers, so the system can preserve its limited PPE, equipment and staff, she said.

Integris on Monday resumed outpatient imaging procedures and is scheduling those in two-week increments to slowly ramp back up, Ibrahim said. The health system has made a lot of progress with respect to disinfection procedures and social distancing in waiting rooms, which there wasn't a playbook for in the past, he said.

For other elective procedures, Integris has initiated a systemwide algorithm to determine what it brings back next. Urgently needed cardiac and oncology procedures will come first, Ibrahim said. The limiting factor, however, is having enough PPE.

"We won't ramp up if we're redeploying our PPE," he said. "For now we're keeping a very, very tight monitor on that."

Oklahoma's governor has given the green light to resume elective procedures on May 1, but Ibrahim said Integris doesn't plan to open things up completely until it is no longer constrained from a PPE and pharmaceutical perspective.

While some providers describe a pent-up demand for surgeries once they resume, others question whether patients will feel safe returning to medical facilities, especially if they are still under stay-at-home orders. Jeff James, CEO of Wilmington Health, the largest independent multispecialty physician practice in North Carolina, met with his leaders on Monday to discuss reopening safely. He predicts patients will be timid for a long time. Nonetheless, James said he thinks it's important to reopen if people are going back to work and need procedures done on nights and weekends.

"I don't know that it will be because there is going to be a big flood of patients, but I do think they're going to appreciate that we're willing to meet them where they need to be met," he said.

The new guidelines from both CMS and the professional groups leave key decisions up to providers, which hospital leaders said they appreciate. Perry called them "smartly flexible."

"I think it has not taken away the ability, ultimately, for the clinicians to make decisions on the ground," she said. "That to me is extremely important."