Many hospitals and other providers are continuing to perform non-emergency procedures despite the fact that most states are once again seeing an increasing number of COVID-19 cases.
Hospitals say they don't need to delay care like they did in the initial months of the crisis. With four months of the pandemic under their belts, providers better understand how to control the spread of COVID-19. They have better protocols in place to conserve and reuse personal protective equipment and other resources needed to care for patients. And they have more access to coronavirus testing, they say.
There is also a financial need to resume elective procedures and keep them going. Hospitals and physician practices want to reschedule deferred care to fill the holes in their bottom lines sustained when procedures had to be delayed and patients canceled routine appointments for fear of becoming infected.
But more importantly, providers say continuing to put off non-urgent procedures—which often aren't things that can be postponed indefinitely—are causing harm to patients. "We stopped operating on patients during the first increase (in cases) because we knew so little, and because we were nervous about 'was it possible to give these infections to other people?'" said Dr. Catherine O'Neal, Chief medical officer and an infectious disease specialist at not-for-profit healthcare ministry Our Lady of the Lake in Baton Rouge, La.
"And because at that time we were also very, very nervous about our PPE supply. We are trying not to do that again because we saw that that harmed a lot of people. Putting off things is definitely harmful while people are waiting for very needed surgeries," O'Neal said.
When the COVID-19 crisis first took shape in the United States, hospitals deferred non-urgent procedures, largely to conserve bed capacity, personal protective equipment and other resources.
The CMS in March urged hospitals to delay elective or non-essential medical and surgical procedures until the COVID-19 pandemic ended. Later in April, the agency unveiled guidance to help providers in areas that had already experienced a peak in COVID-19 cases resume elective procedures. It said hospitals shouldn't start that process until their regions had experienced a decrease in COVID-19 cases for at least 14 days. Guidance from the American Hospital Association and other groups also included that 14-day rule.
Healthcare providers soon began to reschedule procedures that had been postponed after the initial outbreak of COVID-19 cases had subsided and states began lifting stay-at-home orders and social distancing restrictions. But coronavirus cases are again rising in most states, according to a database maintained by Johns Hopkins University. Confirmed U.S. cases have now blown past 3 million while deaths have reached 128,000, Johns Hopkins data shows.
This time around, many hospitals don't see the need to delay patient care again. The situation has changed sense the first COVID hospital admissions. "People feel comfortable about PPE supply, and also the protocols have been put in place on hospital bed utilization," said Brian Tanquilut, an equity analyst at investment firm Jefferies, explaining that hospitals are assigning some floors or buildings for COVID-19-infected patients. He added that COVID-19 testing is also more available than in the beginning of the pandemic. "I think that's where a lot of confidence comes from," he said.
Dr. Jonathan Gleason, chief quality officer at Philadelphia-based Jefferson Health, said the 14-hospital system is comfortable continuing to do medically necessary time-sensitive procedures because it is confident in its ability to procure an enough PPE to take care of COVID-19 patients and non-COVID-19 patients.
Moreover, early in the pandemic, hospitals were worried about having enough ventilators for sick patients. Inadequate testing exacerbated that issue because hospitals weren't able to predict how many patients may need ventilators, Gleason said. But now Jefferson is also able to perform its own COVID-19 diagnostic tests internally and get results back within hours. The system has also secured additional ventilators should it need them.
O'Neal said that Our Lady of the Lake is better able to conserve its PPE supply than in the beginning of the pandemic. Clinicians leave IVs outside of COVID-19 patients' rooms to minimize the amount of time they have to don and discard gloves, gowns and masks. The health system now also reprocesses its N95 respirator masks.
She and other healthcare executives stressed that hospitals are safe for patients without COVID-19. Of the 80 to 90 surgeries that Our Lady of the Lake performs each day, only 15 to 20 patients are admitted to the hospital. The rest recover at home.
"The risk of that one-day surgery and the COVID-19 risk of coming in now that we've been able to put all these infection control things in place is very low, and the benefits to the patient of being able to have their surgery on time is huge," O'Neal said.
Vanderbilt University Adult Hospital is Nashville, is also continuing to perform scheduled procedures, despite COVID-19 cases in the state rising daily. Shon Dwyer, the hospital's president, said it still has enough capacity to take care of both its COVID-19 and non-COVID-19 patients who need care. Vanderbilt is co-horting patients and reprocessing N95 masks in a way that allows clinicians to reuse them up to 20 times. It is also testing asymptomatic patients before scheduled procedures so that it doesn't waste respirator masks on patients who test negative.
Dwyer said the hospital is consistent with washing hands, wearing masks, limiting visitors and performing symptom and temperature checks on everyone who walks through the door.
"We enforce these things within in our environment, and so they are not variable. If you were to go to the grocery store you'd prob have more risk than if you come into our setting because we are ensuring that we are doing everything consistently," Dwyer said.
She acknowledged that continuing to do non-emergency procedures are also important for the hospital's financial position: "The financial implications of turning off your scheduled business are significant and I think that's a consideration for everyone who works in healthcare," she said.
But most executives said that's not the main consideration. Jefferson Health Dr. Stephen Klasko said there's a growing concern that people will get sicker and die of non-COVID-19 health problems if they keep putting off care.
"You have to recognize that COVID-19 is not the only thing that people," he said. "We are still seeing significantly less people coming to the ED … and some of this is the more that we scare people into thinking the worst place to go is an office or a hospital, the more people are going to die of other things."
Nancy Foster, the vice president of quality and patient safety policy at the AHA said in an emailed statement that "there are major differences between slowly and safely resuming elective surgeries and continuing to offer these clinical services once they have resumed. … Hospitals and health systems have put into place many safeguards to protect patients from exposure to COVID-19 when they come to the hospital for care. It is appropriate for hospitals to care for all of the health needs of patients so long as they can continue to do so safely, effectively and are following state and local laws."