There are many considerations for orthopedic and spine practices and surgeons as they resume elective cases.
Ten surgeon leaders discuss how their groups are planning to ramp up surgeries safely over the next few months.
Question: What is your strategy for ramping surgery back up?
Alexander Vaccaro, MD, PhD. Rothman Orthopaedic Institute (Philadelphia): As restrictions on elective surgery are lifted, our focus is to start with the lowest-risk population based on specialty-specific risk factors and exclusion criteria, such as BMI and immune suppression. Each physician is reviewing all postponed and scheduled surgeries and discussing with individual patients the risks and benefits of their surgery at this time. We are prioritizing coronavirus-free facilities that were not used to treat COVID-19-positive patients, including both ASCs and orthopedic specialty hospitals. However, our main university partner hospital — Thomas Jefferson University in Philadelphia — will be used for complex orthopedic procedures, and a system of care has been established to safely care for patients in this setting. In some instances, we will need to refresh preoperative clearances.
Pending testing capacity, it is our intent to do COVID-19 testing on all elective patients, followed by a 48-hour self-quarantine between testing and the day of surgery. Initially we expect to start at 50 percent of a surgeon's typical daily elective caseload to allow for more extensive room cleaning between cases. Our priority initially will be to reassure patients that we can safely address their care needs. As we develop that confidence and trust with our patients, employees and physicians, we will accelerate the ramp-up.
Jeffrey Wang, MD. Keck Medicine of USC (Los Angeles): We are all excited to be able to resume spine surgery and provide these services for our patients. There is a huge backload of patients who had to postpone their surgeries, and we have still seen new patients via telemedicine who have serious problems and need surgery sooner rather than later. We need to be judicious in our processes to begin doing surgeries. Our strategy is to take the outpatient cases first, in the group of patients who are younger and healthier, to minimize the risk to the patient and to preserve the hospital beds, ventilators and medical staff in the hospital for any potential surge in COVID-19 cases. We will treat the patients at least risk and those that will not overutilize our resources, and continue to be vigilant in keeping hospital beds and resources for patients who may need them.
The next wave of patients will be those who need surgery and perhaps are outpatient stays with 23-hour stays. These again would be the healthier patients at least risk without any preexisting pulmonary disease. They may need to stay overnight, but are shorter stays and still not overutilize any needed resources. Throughout this period, any emergency case will still be done whenever needed, as there are patients who need surgery on an emergent basis. We then, if the resources allow, will incorporate patients with more serious conditions needing elective surgeries as our resources open up. We are also opening some of our operating rooms, staggering start times and keeping some rooms empty in anticipation of any possible need or increase in COVID-19 cases. Of our many sites, we are also making one of the buildings a 100 percent COVID-19-negative facility, where everyone needs to be tested within 72 hours, and everyone is negative. This means patients, staff and anyone who enters the building has to be tested negative.
Owen O'Neill, MD. Twin Cities Orthopedics (Minneapolis): We are starting back in our ASCs with a "COVID safe" environment, so patients know they are receiving their care in the safest facility. This involves PCR-testing the patient two days preoperatively, as well as scheduled testing of all staff in the center every two weeks, with daily symptom reporting and more frequent testing of staff as symptoms dictate.
Brian Cole, MD. Midwest Orthopaedics at Rush (Chicago): Our strategy overall has been guided by several principles, including the federal government's position on essential versus nonessential procedures. We also consider the local orders from Illinois Gov. J.B. Pritzker and the burden of COVID-19 on the health system locally. Being affiliated with Rush, even if we are not providing care in a Rush facility, we are sensitive to the demand for resources at Rush. The decision to resume nonessential elective procedures is made based on the availability of PPE, staff, beds, ICU beds and ventilators as well as the overall ability of Rush to manage the demand and patient surge.
Rush has done an excellent job and we are collaborating on all processes. We are still following guidelines in the state of Illinois since the federal government and executive order is almost exclusively predicated on our ability to flatten the curve so our healthcare system is not overwhelmed. We have a good understanding now of where we are in Illinois and what we need to reduce disease transmission.
The next issue is figuring out how to proceed with the provision of care in a responsible way that continues to maximize patient and staff safety. We are doing that today; we are providing access to essential care and doing it through telemedicine as well as direct face-to-face interactions with all individuals wearing masks while enacting social distancing, proper screening and temperature checks, and recording the proper history for patients and staff. If needed, we can conduct a physical examination and MRI, and we are using our office space for urgent and time-sensitive cases.
We are also performing urgent outpatient surgeries in our ambulatory care centers for time-sensitive cases that are deemed emergencies, including when patients have intolerable pain and significant physical dysfunction as long as postoperative care can be predictably provided. We anticipate being able to perform truly elective procedures again on May 11, with all the appropriate social distancing and protective measures in place. We will pay attention to proper hygiene and details in the OR and go above and beyond while following CDC recommendations, including conducting point-of-care testing for patients undergoing surgery.
Isador Lieberman, MD. Texas Back Institute (Plano): I would not be exaggerating if I did not state that we are enthusiastic about reengaging with our patients. With that in mind, the first strategy is ensuring the health and safety of our patients and staff. We had multiple strategy group meetings to review operations on how to get patients back into the clinic and how to capitalize on what we learned with telemedicine. We have implemented a socially distanced check-in process, a screening and PPE strategy for patients and staff, and a sanitation strategy after each patient encounter.
We have also tailored the clinic schedules to accommodate both face-to-face encounters and telemedicine encounters. Once we were content with the clinic plans, we tackled the surgical ramp-up. All the surgeons and interventionalists provided input. We decided to stratify cases into low risk and high risk, regarding COVID-19 status. We are fortunate in that we have area hospitals that are being designated COVID-19-free, where we plan to provide surgical services to the low-risk group. We are screening all patients a minimum of 48 hours prior to surgery, and they are being asked to continue isolation until their arrival for surgery. All of these strategies are fluid, and we do expect changes as we encounter new regulations and/or clinical COVID-related issues.
David Rahija. Skokie (Ill.) Hospital: Evanston, Ill.-based NorthShore University HealthSystem has a comprehensive plan to ramp up surgical and elective procedures starting May 11 while keeping our patients safe. We have robust screening processes and infection prevention protocols to ensure our patients receive safe, high-quality care. In addition, we will have enough resources to continue to provide care for the COVID-19 patient population.
Jason Scalise, MD. The CORE Institute (Phoenix): Throughout this process, we have continued to care for patients' urgent and acute musculoskeletal needs. Given the size of our organization, that continued to represent a considerable number of patients. We have adhered to local and national guidelines and postponed elective surgeries but have been in constant communication with patients who have been affected by this. We have prioritized patients based on most urgent needs as the restrictions begin to be eased. We have already planned for additional work hours at facilities such as our surgical specialty hospital to accommodate the surge in demand.
Oren Gottfried, MD. Duke University School of Medicine (Durham, N.C.): We are very cognizant of the potential impact of our spine care, including surgeries on future capacity issues and the overall focus on care of COVID-19 patients. Additionally, we are aware that many of our patients have significant comorbidities and may not feel comfortable having surgery until there has been a significant decline in new coronavirus cases or deaths. We are gradually assessing proceeding with some of the cases that were postponed by patients at the onset of COVID-19. We believe a slow, gradual increase is safest. Starting at lower volume and keeping a close observation on safety issues for our patients needing elective surgeries will be key.
Brian Gill, MD. Nebraska Spine Hospital (Omaha): Nebraska is resuming elective surgeries as of May 4. We have been developing protocols within our clinic as well as coordinating with the local hospitals to address this ramp-up of surgical cases. We want to make sure that we keep our patients safe. Throughout this pandemic we have continued to see patients who are hurting and need surgery, so our backlog has grown. My estimation is that we have 100 to 200 cases to schedule.
Richard Chua, MD. Northwest NeuroSpecialists (Tucson, Ariz.): We will be following our hospital, county and state health department, governor's office, CMS and [American College of Surgeons] recommendations, and plan on resuming very limited elective surgeries on May 1. These will be limited to outpatient/observation cases; patients must be discharged from the hospital by 9 p.m.; and all patients must be COVID-19-negative on antigen tests performed 48 to 72 hours prior to surgery. Other specifications include adequate hospital bed capacity, adequate PPE and several others. If the hospital is unable to maintain the certification guidelines, then we will be shut down for a minimum of two weeks.