After almost seven weeks since effectively ceasing all nonessential surgeries, Hospital for Special Surgery is making a gradual return to performing urgent procedures.
The New York City-based health system at the epicenter of the COVID-19 pandemic in the U.S. is resuming selective nonessential urgent orthopedic procedures at its three outpatient facilities and transitioning its hospital back to a dedicated musculoskeletal center.
"With the onset of the pandemic, we needed to pivot," said Douglas Padgett, MD, associate surgeon-in-chief at HSS. "In March, we effectively converted into a med-surge hospital to help our partner New York Presbyterian Hospital, which was being overwhelmed by patients. We accepted in transfer a number of critically ill patients with COVID-19, including patients requiring ventilator support."
The hospital typically has the capacity for about 120 inpatients and performs the full spectrum of orthopedic surgery, including spine surgery, total joint replacements and sports medicine procedures. Since March 17, when HSS suspended nonemergent procedures, the hospital's orthopedic census dropped about 90 percent.
"We took our ninth-floor suite of ambulatory surgery ORs and post-anesthesia care unit and converted them into a COVID-19-ICU unit. We also converted several of our patient floors and turned them into COVID-19 units," Dr. Padgett said. "One standard orthopedic floor was turned into a telemetry unit. We had a remote setup with baby camera devices to limit the need for nurses to go in and out of the rooms. We improvised to accommodate for the situation."
HSS' last remaining COVID-19 patients are awaiting discharge and the process of returning to a "new normal" is being implemented. "We're taking all the COVID-19 floors and doing a terminal clean, using disinfectants and other types of cleaning agents to sanitize all of the floors and surfaces," Dr. Padgett said. "Items that are difficult to clean such as drapes and cloths are all discarded."
Floor-by-floor, the hospital is conducting this thorough terminal clean and preparing for the day when it can get back to business. Following cleaning, an environmental survey is performed, taking microbiologic swabs to ensure that the facility is safe for patients and staff. The results of the survey typically returns in three to four days.
Every patient entering the hospital is screened for signs and symptoms of COVID-19, including fever, cough and shortness of breath. Protocols for surgical patients have been developed and include viral PCR testing of all patients within 24 hours of surgery. Serologic antibody testing, baseline pulse oximetry and chest X-rays are also being implemented.
On the outpatient side, every patient is presumed to be COVID-19-positive and staff are equipped with the necessary personal protective equipment such as masks, gloves and eye protection. Daily screenings are carried out and employees are also having their temperatures taken within two hours prior to the start of their shift.
"On the staff side, we're in the process of doing an entire enterprise-wide antibody testing," Dr. Padgett said. "New York State Gov. Andrew Cuomo wants that information and it will give us an idea of what the potential for exposure is for our staff."
"We'll be looking closely at areas where people are at higher risk for exposure — our coronavirus-ventilated units and coronavirus-positive floors — and determining the exposure of hospital staff, compared to the 25 percent of staff that have been working from home, such as IT support and finance." The enterprise-wide survey is taking place through May and aims to uncover the prevalence of COVID-19 in staff working at the hospital and those working from home.
Testing remains a top priority at HSS. Like most healthcare facilities across the country, the shortage of reagents for COVID-19 PCR viral testing remains an area of concern.
"Currently we've probably got about 1,500 testing reagent kits for patients testing," Dr. Padgett said. "We are not viral testing our staff at this time. If we tested the entire hospital staff, we wouldn't even get halfway through. We'd run out of reagents. The good news is that coronavirus-related ER visits and hospitalizations continue to decline on a very linear basis, so I think we're on the downswing here in New York City."
With the health system resuming urgent and emergent procedures at outpatient facilities as of May 6, it's important to ensure that these patients are going home after surgery, according to Dr. Padgett.
"The prevalence of COVID-19 in skilled nursing facilities where people are in such close quarters — many of them elderly — has been associated with unacceptably high morbidity and mortality rates," he said. "As we're dipping our toes in the water, we're trying to do the right indicated procedure in the right patient and monitoring what the outcomes are."
As an orthopedic surgeon with more than 25 years of experience, Dr. Padgett has found that as a result of the current pandemic, many of the routine patient interactions have changed. Healthcare workers are adapting to the new norm of surgical masks, protective eyewear and limited physical contact.
"Life is like a pendulum," he said. "Hopefully we can return to the days of a handshake, a warm hug and the intimate relationship, which had developed with patients in the past. However, in the short run, the new norm is going to be social distancing, the use of PPE and increasing use of telehealth. But I bet in the end, healthcare will be a lot more safe and efficient."
As for when elective surgeries will be able to resume in New York City, Dr. Padgett was cautious about hazarding a guess.
Channelling the words of the late New York Yankees catcher, Yogi Berra, Dr. Padgett said "you always have to be careful about making predictions — especially about the future."