by Elizabeth Hofheinz, M.P.H., M.Ed.
As decision makers cautiously begin to allow the resumption of elective procedures, OSN is talking with orthopedic surgeons about what approaches are being taken and how things are proceeding.
May 27, 2020
From Scott D. Boden, MD Professor and Chair, Department of Orthopaedics, Emory University School of Medicine and Vice President of Business Innovation for Emory Healthcare:
“At the Emory University Orthopaedics & Spine Hospital (EUOSH), we reduced care to only emergent, urgent, and time sensitive surgeries on March 16th. In the interim, we developed video telemedicine workflows by repurposing many of our front desk and other administrative staff to facilitate patients connecting via Zoom and uploading imaging studies in advance of their telemedicine visits. As a result of these early efforts, we were able to maintain approximately 40-50% of our usual patient visit volume and are now approaching 70% of historic volumes. On May 5th, we expanded our surgical procedures to essential surgeries, restarted ambulatory surgeries, and our surgical volumes are approaching 90% of pre-COVID levels.”
“As part of the restart protocol we are PCR testing surgical patients that will undergo general anesthesia or may stay overnight. We are also following universal respiratory precautions during the intubation/extubation, and 15 minutes after each by having staff in the OR wear N95 respirators and by waiting 15 minutes between patients to allow for adequate room air exchanges. These protocols are in effect since patients with a negative PCR test could have turned positive since the test due to the incubation period of the virus.”
“My primary concerns are that community spread is the most likely way our staff will acquire COVID-19 given our strict social distancing with mandatory masking of staff and visitors and the risk of asymptomatic or pre-symptomatic spread continues. Keeping staff from congregating or eating in small lounges or conference rooms will remain a priority for minimizing the risk of spread in the workplace.”
From Jim Bradley, M.D., Clinical Professor of Orthopedic Surgery at the University of Pittsburgh School of Medicine:
“At this time, prior to surgery patients are being tested for COVID-19. If they are negative, they will proceed with continued CDC guidelines and staff wearing recommended protective gear. If they are positive, asymptomatic, and the surgery is deemed urgent and can’t wait until the patient recovers the patient is allowed to proceed with permission of the COVID-19 team and strict guidelines are followed for staff and patient to prevent spread of the virus. If they are positive and have symptoms the surgery is cancelled until they are recovered.”
“My biggest concern is always patient and staff safety however, I think we have safe guidelines that we have been and will continue to follow to continue necessary care.”
“As people begin to converge in their normal daily routines, there is an inherent higher risk of transmission of the virus. When you see a patient in the office you won’t know the degrees of separation you have from the virus, but we haven’t known all along. So, from my perspective nothing changes really. I think that we have to continue doing what we know works; frequent hand washing, wear masks, practice physical distancing, screening patients for symptoms, and cleaning the patient rooms in between patients. All these preventative measures take time, which will inherently slow down volume of patients that can be seen in the office.”
May 20, 2020
From Elizabeth Matzkin, M.D., Chief of Women’s Sports Medicine at Brigham and Women’s Hospital and Associate Professor at Harvard Medical School:
“We have several task forces set up to work on protocols and plans to return to elective surgery. Plans will initially be to start doing elective procedures at our off-site centers that will be considered Non-COVID care zones vs the main hospital where ongoing treatment of COVID patients will continue. All surgical cases will be assigned a priority to determine how urgently the procedure needs to occur. Type of surgery, resources required, and patient risk factors will all need to be considered when scheduling cases.”
“The biggest concern about returning to doing elective cases is having staff members or patients exposed and infected with COVID. This will require that there is routine screening of all staff (MDs, PAs, RNs, scrub techs, housekeeping, etc.) to ensure they are COVID negative. Similarly, all patients would require screening before their procedure.”
“Prior to resuming elective procedures, we need to be certain that there are adequate resources available including a healthy workforce, COVID testing capabilities and ample PPE. Both floor and ICU bed availability will need to be monitored daily.”
“As we start to reopen the ORs and clinics, we have to be prepared to change how ‘we used to practice.’ Getting back to ‘normal’ will take a very long time, but most likely will never be the same. Things will need to change, and change is always challenging.
Challenges will include:
- We will need to monitor supplies available.
- We will need to practice social distancing.
- Busy waiting rooms are not acceptable.
- We will need to integrate in-person and virtual patient clinic visits to be efficient.
- How we work with PA, fellows, residents and medical students will need to change
- We will need to limit exposure of each patient to staff (check-in, medical assists, APPs, schedulers, xray techs, etc)
- In the OR, we will need to get used to wearing N95 masks and making sure they are available for all personnel working there
The safety of our patients and workforce will be the number one priority.”
From Peter Krause, M.D., the Elaine A. Doré Endowed Chair in Orthopedics and Vice Chairman of the Louisiana State University Health Sciences Center Department of Orthopaedic Surgery and Director of Orthopaedic Trauma University Medical Center in New Orleans:
“We have our eyes open for the next wave: if and when it will come and how bad it will be. While hospitals are taking cues from the federal and state governments, since New Orleans was a hotspot, everyone is taking additional care here. We are going by a tier system where the patients who have more serious problems and who have been waiting longer are the first to have surgery.”
“Many patients are reaching out to me in order to get scheduled for surgery. In addition to trauma, I do elective hip replacements in patients with severe arthritis who have very limited mobility. Most of the patients who have reached out to me are very disabled by hip problems and not working because of their condition. I have a few patients who are continuing to work despite the pain of serious hip pathology.”
“As a physician, it is truly frustrating to have patients who are in serious pain and looking to me for help and I cannot provide them with solid solutions and a surgery date. I, too, have to take cues from the hospital system and government. Some surgeons thought that because we were delaying cases, that we would end up with a large spike of patients having surgery, but that has not happened. Hospitals are limiting their surgical schedules to 25 and 50% of their normal volume. The clinic schedules are also very limited. And we still have patients with urgent and emergent problems who need to be treated. Since Louisiana opened up to limited, time-sensitive elective surgeries on April 27, I have only done one outpatient procedure.”
May 13, 2020
From Roy Sanders, M.D., Chairman of the USF Deptartment of Orthopedics, President of the Florida Orthopaedic Institute, and Chief of Orthopaedics at Tampa General:
“We have resumed elective surgery, but every patient is screened and then tested before surgery is allowed. While this is not foolproof it is better than a simple screening procedure as many patients are asymptomatic carriers, and don’t convert until a few days later.”
Asked about his most significant concern, he noted, “Clearly, that 5% of patients will fall through the cracks and we will be operating under relaxed protocols on someone who converts a few days after we treated them.”
“Everything is slower and staffing is still spotty. This latter issue is due to kids at home, family members of staff being positive, layoffs and unemployment which allows some staff to stay at home rather than return to work. Finally, a new local outbreak as return to normal will increase transmission. Since we can expect this to return or have a resurgence, it is difficult to predict how we will be able to resume completely normal operations in the foreseeable future.”
From Peter J. Millett, M.D., M.Sc., The Steadman Clinic in Vail, Colorado:
“We resumed full orthopaedic services last week and have implemented best practice guidelines. While many surgeries were delayed during the shutdown, I think the term ‘elective surgery’ isn’t ideal because no one really wants surgery. Many patients need orthopaedic surgery to eliminate pain, to restore function and to allow them to work. We feel good about reopening as we live in a rather rural area where the number of new Covid cases is now almost down to zero. Thus, there seems to be limited risk of overburdening our healthcare system, and moreover no one in our county has been intubated for Covid-related illness in more than six weeks.”
“Patient response has varied, with some people wanting to get surgeries done ASAP because they have been waiting and are in pain. Some want to have surgery now because they have been furloughed, but still have healthcare benefits. Some prefer to wait and see. We are asking our surgical candidates if they have had any recent Covid-like symptoms or exposure to sick or Covid-positive individuals. If they reply ‘yes,’ then we ask them to self-quarantine for 2 weeks.”
“We now have a rapid/same day PCR test for Covid and are introducing this. The antibody tests developed so far don’t have great sensitivity and specificity, and there is some variability in the biological response, so the exact meaning of these tests is unknown. So testing is still a bit murky…someone could test negative, but by the time he or she undergoes surgery the disease could be present. At this time, we are offering preoperative testing, but we are primarily going by patients’ symptoms, risk profile, and the extent to which patients have been social distancing.”
“To protect our staff, we are taking universal precautions by assuming that everyone could have Covid. During intubation there are no extra staff members in the room, our anesthesia colleagues have special masks and PPE, and the patients and staff wear masks at all times. We have also moved the majority of our surgeries to our ASC, which has been kept completely free of Covid patients.”
“Thus far, there have been no issues with our reopening. Vail Health together with our county and state have been doing an excellent job of managing the situation. In fact, we were permitted by the Governor to be the first county in Colorado to re-open. The fact that we have not seen resurgence of cases gives me hope that we won’t see a big surge and have to shut down again. It also gives me hope that some Covid treatments are showing efficacy. The initial modeling of the disease seems to have vastly overestimated its severity on a national level. Certain regions have no doubt had a terrible experience; we have been fortunate in part because we are more rural and thus it has been easier to social distance.”
“There is perhaps a silver lining in that this experience has forced us to start using telemedicine. I think that will be an appealing adjunct to our practice and will probably change the way we do orthopedic care. Yes, in some ways tele-health visits are more difficult…for example, it is harder to evaluate someone’s body language, to palpate or to assess strength, but I am confident that we will come up with ways to adjust. There will be many ‘new norms’ when this is all over!”
Vail Health Clean Clinic Promise
- All staff are required to wear a mask.
- All patients and visitors are screened for COVID-19 symptoms.
- All patients and visitors must wear a mask while present in the facility.
- Only one visitor per patient in the hospital, to decrease traffic.
- Removal of commonly touched items, like magazines.
- Make every effort to provide for comfortable social distancing.
- Surgical patients are screened three times prior to arrival.
- All of our disinfectants are approved for use against human coronaviruses.
- Equipment used with a patient is thoroughly disinfected between use.
- Additional cleaning and disinfection of high touch surfaces.
- Provide ample hand sanitizer and adopt increased hand-washing standards.
- Staff are not permitted to work with any COVID-19 symptoms.
- Cafés serve grab-and-go items and menu options that reduce the risk of exposure.
- Edwards Medical Campus is a well-campus and CMM Avon is a well-clinic with no COVID-19 patients.
- Vail Health will maintain separate, isolated COVID-19 patient areas in CMM Vail and Eagle locations, and Vail Health Avon Urgent Care.
May 11, 2020
From Vinod Dasa, M.D., Associate Professor of Clinical Orthopaedics and Director of Research at LSU Health Sciences Center:
“While there is a lot of interest in planning for a ramp up, there is a dearth of leadership guidance on how to proceed. Just because I want to do surgery and the hospital wants to restart doesn’t make for a smooth runway. Consider the issue of preoperative Covid testing…when should it be done…24, 48, 72 hours beforehand? The tests are only about 70% sensitive anyway, so some ‘negatives’ will actually be positive. There needs to be in-depth discussion around what risks we are willing to accept. There is inconsistent guidance from various entities so for the time being, we may have to treat everyone as if they are positive for the virus.”
“There are so many unknowns…How will hospitals fair with surgical revenue for 2020? Physicians are taking pay cuts and losing vacation…and if we are among the most resilient professions during a recession, that doesn’t bode well for things overall.”
“Roughly 20% of working Americans are unemployed and the remaining workforce is experiencing pay cuts and lost vacation time—and these are the patients who represented a lot of the profit margin in health care.”
“Another substantial issue is that older patients are scared. Many of us are handling this by trying to get out in front of the problem, saying, ‘This is what we are doing to ensure your safety.’”
Shedding light on an unusual complication of Covid-19, Dr. Dasa says, “There is this odd phenomenon where some patients are getting very red toes…as if they had frostbite called “Covid toes.” It may be dysvascular toes, but no one understands why this is happening. It could be microemboli and may need more research on DVTs and PEs among Covid patients.”
“Or it could be a systemic inflammatory response. This is a sign that we don’t have a handle on the medical complications involved with this disease, let alone the surgical complications. Let’s say someone tests negative, undergoes surgery, then they enter a post surgical inflammatory state. So we have induced this with surgery and now they go home and are vulnerable to the virus. But what should we do? Some patients are just so miserable that they must have surgery. I had someone crying in my office the other day, basically saying, ‘I can’t stand the pain. You have to do my surgery.’ Should we be more aggressive with DVT prophylaxis? Should we see patients earlier than six weeks postop?’ There are a lot of headwinds for 2020-2021.”
From Jeffrey A. Goldstein, M.D., Chief of Spine Service-Education, Director of Spine Fellowship, and Professor of Orthopedic Surgery and Neurosurgery at NYU Langone Health:
“At NYU Langone Health we are presently taking care of patients who require medically necessary surgery that can no longer be delayed. Getting back to orthopedics all of our faculty, house staff, nurses, staff and company representatives all require COVID testing. All patients are also tested before surgery. People entering the hospital are questioned about symptoms and temperatures are taken. Patients who are undergoing surgery require a negative test prior to surgery. If they are asymptomatic but COVID positive then surgery is delayed two weeks if medically appropriate, when it is anticipated that there will be no live viral shedding. All COVID positive patients also obtain D-Dimers to evaluate the potential risk for thromboembolic disease. Specific protocols are in place for prophylaxis for these patients.”
“New York is in a hotspot. This has given our institution tremendous experience with the treatment of COVID patients and provided a significant amount of data. We have closely scrutinized our experience to better understand what the risks actually are and take a scientific and practical approach to safely treat our patients and protect our staff. There is understandably a lot of emotion and many have suffered losses physically, emotionally, and economically. Our scrutiny of the data has allowed us to come back online through a carefully thought out and calculated approach.”
“We have acquired a tremendous experience over the last several weeks. The challenge is to disseminate the data to our colleagues, patients, and staff. The lay press is full of many anecdotes and many experiences which may or may not apply to your institution or demographic. It is important to let folks know what the data show and where appropriate alleviate fear which may potentially be misplaced. That is not to say that a significant amount of vigilance doesn’t need to remain in place. This is constantly changing as our knowledge and experience increase.”
May 6, 2020
From Wael Barsoum, M.D., CEO and President of Cleveland Clinic Florida and the Robert and Suzanne Tomsich Distinguished Chair in Healthcare Innovation:
“On Monday, May 4, the Cleveland Clinic Florida region began increasing our outpatient appointments, surgeries and procedures that were paused due to the COVID-19 pandemic. We also expanded surgeries and procedures we were already performing under the Florida Department of Health guidelines to include elective surgeries and procedures.”
“The safety of our patients and caregivers remains our top priority. We want to assure patients that our Cleveland Clinic facilities are safe for them to receive care. For nearly two months, we have taken steps to increase safety by limiting visitors and screening them for potential COVID-19 symptoms, providing essential Personal Protective Equipment for caregivers, practicing physical distancing, expanding testing capabilities and continuing to clean our facilities extensively. We are also requiring everyone on our campuses to wear masks while at work.”
“By acting quickly in the early stages of the pandemic, we ensured that Cleveland Clinic is a safe environment for our patients and caregivers. Less than 1% of our caregivers have become ill with COVID-19, with the vast majority contracting it through community spread.”
“We have maintained that same diligence and rigorous dedication to safety as we resume broader operations. For example, we are working closely with physicians to determine which patients have the highest need for surgical procedures after being delayed for a month. We will remain nimble if there is a surge of COVID-19 positive patients that need hospitalization.”
“We are also testing every patient for COVID-19 prior to their procedure, for the protection of patients and caregiver as well as keeping portions of all of our hospitals COVID free.”
“We have had a fair amount of time to plan for reopening and feel we are well prepared, despite the uniqueness of this situation. We have multidisciplinary teams working together more closely than ever, and there is an enhanced sense of teamwork that has developed across the whole organization. We are acting as a collective unit and operating in a very nimble fashion.”
“Much of what we do in orthopedics, although considered elective, is really not when you consider the enormous quality of life improvements and relief from suffering that these surgeries provide. Unfortunately, the economic effects COVID-19 will have on the communities we serve may play a role in people’s decisions whether to have orthopedic surgery or not.”
From Paul Tornetta, III, M.D., Chair, Professor and Residency Program Director in the Department of Orthopaedic Surgery at Boston University School of Medicine and the Director of Orthopaedic Trauma for the Boston Medical Center:
“There are many things to consider including the balance between the risk of disease transmission to both patients and staff and the stock of PPE. We will be testing all patients prior to surgery and staff at some regular intervals. We will be practicing social distancing in all areas, not allowing visitors, requiring masks, and planning carefully to isolate patients from inpatients who are COVID(+) or PUI [patient under investigation].”
Asked about his biggest concerns about this process Dr. Tornetta noted, “Finding the proper balance between the use of full PPE and the need to be prepared for the next wave of illness that is incredibly likely. This is particularly important given that in my opinion we do not have firm accurate data on the false negative rates of PCR testing of various types in asymptomatic patients who may still be able to spread the virus.”
“The overarching concern is to be flexible and have starting, accelerating and more importantly, slowing and stopping rules based on the COVID disease prevalence, new reported regional and local cases and admissions. We cannot make an error that results in the lack of PPE for frontline doctors, nurses, and other care givers when a second wave of illness hits. I fear that locations lucky enough to have missed the first wave will have a false sense of security and be hit hard by an unexpected surge that could leave many without medical resources or protection.”
May 5, 2020
From Jeff Wang, M.D., Chief of Orthopaedic Spine Service and Co-Director of the USC Spine Service:
“We planned meticulously for a surge and were relieved when we were not overwhelmed and we are able to treat all of the patients with covid-19, and maintain safety measures for our patients, and employees. We are planning on resuming elective cases beginning May 4 and are thrilled to be able to get aid to the many patients who are in pain and need surgery. While shutting things down was the right call, suspending elective surgeries in the last six weeks has been difficult for us, as we see our patients who are in so much pain.”
“I recall when we started the shutdown there were days leading up to the official shutdown—about a five- or six-day window—where some practitioners shut down while others kept operating at their regular pace. It was an uncertain period with little official city or state policies. We are opening up with some of that same uncertainty, of whether there will be another spike in cases, and if we will need to have another period of time where we stop elective procedures.”
“We are starting to see surgeons do cases that are urgent elective but not so very urgent…so people are starting to push boundaries. Notably, when we do commence, we will begin with younger, healthier patients who are at the least risk, and we will do the outpatient cases first, to allow them not to have to stay in the hospital. This is safer for our patients, and still preserves hospital beds and ventilators if they are needed. And from an operations standpoint, if a second wave hits us then we are still preserving needed resources so we can handle and care for those patients.”
“The decision of whether or not to operate on someone is made by committee. To a great extent we are keeping an eye on the amount of resources that any given surgery would involve—again, in the event of a second wave of Covid.”
“We are using our ASCs and have a designated hospital building that is going to be totally Covid-free. Everyone who enters must have tested Covid-negative within the previous 72 hours. As for our main OR, we have cordoned it off. There is one section that has been walled off and anyone who is Covid positive or suspected of having Covid is undergoing surgery in those rooms. These measures have helped our patients feel safer overall.”
“On a professional level, this pandemic is crashing careers. I have friends, people in their late 50s, who are retiring because of Covid-19. Their reasoning is that due to staggering patients and social distancing measures, they won’t be able to do enough cases to pay for all of their overhead.”
From Dan Riew, M.D., Professor of Orthopedic Surgery, Columbia University, Chief, Cervical Spine Surgery & Co-Director, Spine Division, Co-Director, Columbia University Spine Fellowship:
“We’ve been doing telehealth visits and I am pleasantly surprised by how helpful it is. I plan to continue to use this to some extent even after the crisis. The numbers of cases in New York have continued to fall. We anticipate being able to do elective cases now at the beginning of June if things continue on this trajectory. At our hospital, there appears to be adequate PPE.”
“We are doing all ortho cases in the New York Presbyterian hospital system at one hospital, which will be cleared of all COVID-19 cases. We have all been asked to prioritize the cases according to their urgency. We will test all patients 1-2 days before the procedure and start with the healthy, young patients with the most urgent problems.”
“We must put our patients and staff at ease that we are taking appropriate precautions to prevent any infections. I believe that with all the precautions that we are planning to take, the risk of infecting someone is extremely low.”
“How to see patients in the office will be much more difficult that doing operations, which is in a controlled setting where we are taking care of one person at a time. How do we handle the waiting room? How do we make sure that someone with an infection isn’t going to contaminate our office? How do we connect with someone when everyone is wearing masks?”
May 4, 2020
From James D. Kang, M.D., Thornhill Family Professor of Orthopaedic Surgery a Harvard Medical School and Chairman, Department of Orthopaedic Surgery at Brigham and Women’s Hospital:
“Although model projections vary, we seemed to have reached a plateau at our Mass General Brigham (MGB) Health System which is experiencing an overall COVID patient census hovering around 800-850. We still have capacity for more COVID patients here at the Brigham; as of April 27, we had 54% ventilators available. We are hopeful we will see a slow downturn in the “curve.” The governor still has a stay-at-home advisory in place until May 18.”
“As of yet we have no greenlight for elective surgeries. We can do some spine cases where patients are experiencing foot drop, or tumor cases and trauma. Approximately 75% of our administrative team in the orthopedic department have been deployed to other parts of the hospital. Some of our residents and a few of our fellows are working in the COVID-19 ICU and some have been sent to medical services.”
Regarding the impact on surgical training, Dr. Kang notes, “Orthopedic fellows may end up missing up to 25-30% of their surgical experience, so they may be somewhat uneasy that they did not get the full training experience. Unfortunately, we can’t keep them around for an extra two to three months. They will however have had enough essential training as a foundation to continue their learning on their own and perhaps come back periodically for refinement.”
“Although I believe we are doing the right thing, I am definitely concerned about the downsides of everything being shut down. We have seen a drastic reduction in people coming in for heart attacks, strokes, and the like avoiding needed care due to fear. We may see a rise in non-COVID death rates as a consequence. And there are so many other unknowns with this virus and no definitive end in sight. And to what extent should we implode the world economy, not to mention the negative financial impact to the US health system as most hospitals head towards the brink of insolvency?”
Looking forward, Dr. Kang sees the possibility of a second surge of COVID. “If we hit the second wave in the fall and winter, it will coincide with the normal flu season and that will again completely sap our manpower and PPEs. Each patient on a ventilator requires significant resources, so we could very well be overrun again in certain “hotspots.” We may even face shortage of nurses for non-COVID patients who have heart attacks, strokes, etc.?
“The PPE shortage may be exacerbated with businesses opening up. Every person working in a nail salon, hair salon, etc., is potentially going to be clamoring for an N95. Here at Mass General Brigham health system, we are recycling 80,000 N95 masks a day, but that may still not be enough to cover all elective surgeries.”
“I think Boston will see the light at the end of the tunnel in a month or so. But reopening has to be tailored to the science of testing as well as antibodies…and we need better, faster tests. At this point it looks like, we will be able to perform elective surgeries starting in June, but the ramp up may be just as difficult due to continued safety issues. Nevertheless, we in the orthopaedic family are all anxiously waiting to get back into our clinics and operating rooms so we can help all of those patients who have been sidelined and have suffered with their musculoskeletal ailments.”
From Nitin Khanna, M.D., an orthopedic surgeon with Spine Care Specialists in Munster, Indiana:
Any pathway back to normal, says Dr. Khanna, is inevitably local in nature. “There are many location-specific factors that come into play. What New York City looks like is going to be very different from Wyoming. Similarly, there is a big difference between major hospital systems that have been hammered with Covid patients and smaller facilities that have not experienced that phenomenon.”
“With the right leadership, coordination, and execution, some facilities could create a hospital within a hospital…essentially having a safe zone that is completely Covid-free. However, you could do your best to create this, but if patients are scared then that is a serious obstacle.” It will be key for the provider and facility to be able to articulate their safety protocols to patients.”
Turning to the pain control issue, Dr. Khanna says, “We use the terms ‘elective’ and ‘nonelective,’ but what does that mean exactly? There are so many people in great pain but have comorbidities that make the situation more delicate. If we’re talking about a total joint replacement in an 80-year-old with hypertension and diabetes, then that patient should wait as long as possible.”
“When I was a resident 18 years ago, we started looking at pain as the fifth vital sign and were thus hyper-aggressive with pain management. Orthopedic surgeons are vilified if we prescribe opioids, but these are special circumstances. Perhaps it is indeed safer to delay surgery and use more of an aggressive pain management protocol in some patients.”
“Another piece of this is site of service. The challenge is that there are so many political considerations. Hospitals are feeling the financial pressures to safely resume elective surgery, but if an ASC is an option, it is probably a safer site of service choice at this stage of the pandemic. The government will have to step in and provide pathways that provide for the safest possible options for patients…if a case can be safely done in an ASC then it should be.”
May 1, 2020
From Alex Vaccaro, M.D., Ph.D., M.B.A., President and CEO of the Rothman Orthopaedic Institute:
“At this point, we are focusing on patients who, without surgical intervention, would clinically deteriorate. Every patient is being tested for Covid at least 48 hours before their surgical procedure. We have the ability to test the same day but prefer not to do that if possible for logistic reasons. Since the tests have varying degrees of reliability, our lab is using both testing platforms. We are doing our best with a moving target…last week six Covid patients came back negative on the rapid 2-minute test but then turned up positive when the other test was run.”
“Ideally, we would like all healthcare workers to be tested for the antibodies to the virus, but we are not there yet. But one day it may be normal for a patient to say, ‘Hey doc, I have the antibodies to the virus, how about you?’”
As for visitors, Dr. Vaccaro has made only one exception. “If a patient is handicapped then we allow him or her to have one visitor, providing that they undergo a Covid test.”
“Let’s say you have a patient with a progressive foot drop who doesn’t want to be seen in the office. So they get an MRI, it is uploaded via telemed and I see a massive disc herniation that merits surgery. Some insurance companies have a new trick where they are saying, ‘We cannot approve surgery because you didn’t do an in person physical. Or you need to get a second opinion.’”
Asked about his concerns over the next 30 days, Dr. Vaccaro goes broad: “I think the biggest issue is whether this crisis will ultimately alter the way we interact with patients. It will certainly allow a substantial number of patients to enjoy the benefits of remote healthcare. Also, until a vaccine or cure is available, I think family decision makers will be saying to their loved ones, ‘You’re not going to a hospital until we know you will definitely be safe.’ This will be a tremendous financial stress on an already burdened healthcare system…we must eventually have a vaccine that covers any closely mutable organisms.”
From Thomas Vail, M.D., Chair of Orthopaedic Surgery at the University of California, San Francisco:
“We are ever so slowly beginning to turn the ship around and have begun thinking about how to provide more services and not fewer. In San Francisco we are grateful that we don’t have as many cases as projected; we are not tempting fate, however, and are proceeding with caution. Here in the bay area we now know that the first Covid death was in February, which suggests that we don’t know the true prevalence of the disease at the time when it first became clinically apparent. This puts a lot of statistical assumptions in question and exacerbates the uncertainty that makes planning resumption of services especially difficult.”
“As for when preop Covid testing should be performed, that is an open question. In our clinic we have said that as long as someone gets tested four days before surgery then that is acceptable. Obviously, it is possible that someone could get infected in the time between testing and surgery, but that risk is low when the prevalence of the disease is low. The risk with this is something that you can’t totally eliminate. There are important implications for someone who gets sick after surgery in that their recovery might be affected.”
“We are attempting to employ a standardized protocol for reopening of elective surgeries. First, we continue to prioritize caring for people with urgent problems such as spinal conditions involving weakness. We also want to care for people who have been displaced or are waiting. For example, one month ago we determined that some patients can wait, but at this point that might not be the case and they may need to be moved up on the waiting list.”
“Resources such as hospital beds, PPE, and operating rooms vary from city to city and depend on the burden of Covid-19 in the community. ASCs are a great option, but wherever you operate critical judgment is vital. If someone is hurting and cannot function or they have dependents at home, then those things must also be factored in as well.”
These decisions are inevitably made by committee, notes Dr. Vail. “Once the surgeon and patients come to a decision, the surgeon provides the section chief a list of people he or she thinks need surgery within the following seven days. Then the chief’s decision is reviewed by the chair…and then whatever surgeries are decided on are fit into the grid of available OR times. As capacity increases, the system will be more fluid, accommodating more patients and working farther ahead.”
“We are anticipating that if things continue, we’ll have our shelter in place lifted around the end of May. We are planning a gradual increase in OR access over the weeks of May, and in roughly six weeks or so we could be approaching a fully functioning hospital, albeit functioning in a very different way with lower volume, controlled access, and social distancing. It also helps that here in San Francisco we’ve reopened a previously shuttered hospital for Covid patients…so at least we have a relief valve in the event of a second wave or new concerns.”
Asked if UCSF is allowing visitors, Dr. Vail said, “It’s so painful to witness. As a provider it seems inhumane to not allow someone to accompany the patient. This rule, put in place by the Department of Public Health to protect hospitalized patients and workers, has sound rationale. Unfortunately, the prospect of being alone is particularly daunting for people who do not speak English as a first language, or those who feel intimidated in a hospital setting. We have been supporting exceptions such as in the case of children, delivering mothers, critical care, and end-of-life situations. We hope that the circumstances will allow more patients to be accompanied as testing and screening make it safer.”
“Overall,” says Dr. Vail, “the single area most important variable in safe care is that we can more broadly use and trust the results of the Covid tests. We have to be clear on who has it and who has been exposed to it. This is important because you want to know the prevalence in the community and be able to immediately dampen down any new cases to prevent broader transmission.”
