Return to Electives

[pjl]

What is your plan for how to resume elective surgery at your facility?
-what patients
-what cases
-what volume

When do you see this happening?
-when cases drop to x? stop rising?

What major roadblocks are there for this?
-what testing do you need
-what equipment/PPE will you demand?
-what hospital capacity will you need?

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[ChiDO]

We see hoping to resume elective Orthopaedic procedures may 1 at our asc. Thus that would basically mean healthy young patients under 65. We hope to resume cases at our private hospital for Medicare joints around mid may. Well resume revision totals and sicker patients at the hospital when they allow us too. Tentatively mid may to early June.

Our hospitals are 30-40% full currently with 50% icu capacity and about 5 covid cases.

Ppe supply currently is 30+ days. If all goes well these next few weeks without a spike, then I think the above dates will hold.

 

[AdmiralChz]

We see hoping to resume elective Orthopaedic procedures may 1 at our asc. Thus that would basically mean healthy young patients under 65. We hope to resume cases at our private hospital for Medicare joints around mid may. Well resume revision totals and sicker patients at the hospital when they allow us too. Tentatively mid may to early June.

Our hospitals are 30-40% full currently with 50% icu capacity and about 5 covid cases.

Ppe supply currently is 30+ days. If all goes well these next few weeks without a spike, then I think the above dates will hold.

Wow, I want to get back to more normal work too but May 1 sounds a little aggressive. Do you think you’ll be way on the other side of the curve by then (doesn’t sound like it has really hit you yet). Question of course will be how affected will suburban and especially rural communities are, and the time frame.

 

[gcc322]

Cleveland Clinic delayed electives until June 15th

 

[ChiDO]

Wow, I want to get back to more normal work too but May 1 sounds a little aggressive. Do you think you’ll be way on the other side of the curve by then (doesn’t sound like it has really hit you yet). Question of course will be how affected will suburban and especially rural communities are, and the time frame.

We've been shutdown for 3 weeks here in the midwest. Smaller community, not a major metro area. Hospitals are empty. I don't foresee a large spike, but continued gradual cases. I personally know two +COVID cases who are asymptomatic completely. Thus, I'd guess there's a lot more in the community.

 

[Justice4all]

Do they plan to preoperatively test those patients either day of surgery or prior and would n95 be available if you don’t?

 

[Pharmado]

I had a urologist question me yesterday about when “we” are going to restart elective cases. Not sure why he thinks anesthesia is responsible for this, but he made sure to let me know that we’d better be willing to work on Saturdays. It made me wonder what world that guy was living in.

 

[vector2]

I had a urologist question me yesterday about when “we” are going to restart elective cases. Not sure why he thinks anesthesia is responsible for this, but he made sure to let me know that we’d better be willing to work on Saturdays. It made me wonder what world that guy was living in.

You saw this, right?

 

[Southpaw]

I had a urologist question me yesterday about when “we” are going to restart elective cases. Not sure why he thinks anesthesia is responsible for this, but he made sure to let me know that we’d better be willing to work on Saturdays. It made me wonder what world that guy was living in.

new job or old job? either way refer him to the CMO of the hospital and tell him to F himself. Great? Thanks.

 

[dannyboy1]

I had a urologist question me yesterday about when “we” are going to restart elective cases. Not sure why he thinks anesthesia is responsible for this, but he made sure to let me know that we’d better be willing to work on Saturdays. It made me wonder what world that guy was living in.

Probably the world where he is effectively unemployed. If he feels this way think about the millions that live paycheck to paycheck. Just wait for the social unrest that will follow if this keeps on for much longer. Lockdowns and the modern economy are incompatible....

 

[pjl]

I had a urologist question me yesterday about when “we” are going to restart elective cases. Not sure why he thinks anesthesia is responsible for this, but he made sure to let me know that we’d better be willing to work on Saturdays. It made me wonder what world that guy was living in.

I don’t know, I get to negotiate with my hospital when we should restart, but they have to have OR staff, PPE and space for patients to go. So I guess I have more say than a given urologist.

When surgeons pester me, I just remind them that I expect 1/3 of my department to be quarantined and/or possibly sick in the ICU over the next few weeks and they seem to stop asking.

The reason I made the thread is so I could hear if others had objective criteria for restarting.

Our current thoughts are:
1: New covid admissions declining.
2: >10 free ICU beds/vents (out of the 50 we usually have
3: Testing capabilities on site.
4: OR and anesthesia staff has returned to OR in adequate numbers to add additional rooms.
5: PPE and machine filter supplies in sufficient quantities with some ability to obtain more.

Patients at startup will be basically ASA 1/2 under 60.
Procedures will be limited to outpatient only.
Total rooms will begin at ~50-75% typical capacity.

 

[abolt18]

I don’t know, I get to negotiate with my hospital when we should restart, but they have to have OR staff, PPE and space for patients to go. So I guess I have more say than a given urologist.

When surgeons pester me, I just remind them that I expect 1/3 of my department to be quarantined and/or possibly sick in the ICU over the next few weeks and they seem to stop asking.

The reason I made the thread is so I could hear if others had objective criteria for restarting.

Our current thoughts are:
1: New covid admissions declining.
2: >10 free ICU beds/vents (out of the 50 we usually have
3: Testing capabilities on site.
4: OR and anesthesia staff has returned to OR in adequate numbers to add additional rooms.
5: PPE and machine filter supplies in sufficient quantities with some ability to obtain more.

Patients at startup will be basically ASA 1/2 under 60.
Procedures will be limited to outpatient only.
Total rooms will begin at ~50-75% typical capacity.

Our hospital is still running at basically 50%, having cut out all totally "elective" cases. ~230 cases a week the past couple weeks. Amazing what our reduced case load is like.

 

[pjl]

Our hospital is still running at basically 50%, having cut out all totally "elective" cases. ~230 cases a week the past couple weeks. Amazing what our reduced case load is like.

We are doing ~5-10% usual volume. Very painful financially.

 

[jwk]

Our hospital is still running at basically 50%, having cut out all totally "elective" cases. ~230 cases a week the past couple weeks. Amazing what our reduced case load is like.

Amazing what people will consider "urgent" cases. If you're doing 50% of normal, you're way ahead of most.

 

[jwk]

I don’t know, I get to negotiate with my hospital when we should restart, but they have to have OR staff, PPE and space for patients to go. So I guess I have more say than a given urologist.

When surgeons pester me, I just remind them that I expect 1/3 of my department to be quarantined and/or possibly sick in the ICU over the next few weeks and they seem to stop asking.

The reason I made the thread is so I could hear if others had objective criteria for restarting.

Our current thoughts are:
1: New covid admissions declining.
2: >10 free ICU beds/vents (out of the 50 we usually have
3: Testing capabilities on site.
4: OR and anesthesia staff has returned to OR in adequate numbers to add additional rooms.
5: PPE and machine filter supplies in sufficient quantities with some ability to obtain more.

Patients at startup will be basically ASA 1/2 under 60.
Procedures will be limited to outpatient only.
Total rooms will begin at ~50-75% typical capacity.

I think the rapid-result testing will be key - and I hope they test all of us between now and the re-start. I'm not sure if we'll have a lot of restrictions on patients. Our total joint guys are going crazy (among others). If we've got adequate PPE supplies, I think we'll ramp up sooner rather than later assuming testing is readily available.

 

[abolt18]

Amazing what people will consider "urgent" cases. If you're doing 50% of normal, you're way ahead of most.

Well, the person approving "urgent" cases is a gyn-onc surgeon so all of these cancer surgeries keep happening. Even the laryngectomy w flapthat takes all day and requires that EVERYONE in the OR wear full PPE. EGD for NG placement in 89yo demented woman who doesn't want the NG. Classic.

 

[Justice4all]

Peds. We are were @ 20% case volume. Definition of elective is loosening a bit. Now currently at 40-45%. With rapid testing starting in upcoming weeks , I expect an increase in volume.

 

[kmurp]

We have exactly one case tomorrow. And our hospital just terminated their employee neurosurgeons as did the other local private hospital. The academic medical center near us is salivating over how they will come out ahead at the end of this.

 

[Justice4all]

We have exactly one case tomorrow. And our hospital just terminated their employee neurosurgeons as did the other local private hospital. The academic medical center near us is salivating over how they will come out ahead at the end of this.

That seems drastic. We’re they just doing elective spines only?

 

[kmurp]

That seems drastic. We’re they just doing elective spines only?

They had lost most of their volume to the academic center. The program was losing money, and now the hospital is bleeding money. They won’t be the last to be terminated and I expect our hospital to lose its independence by the end of the year.

 

[Zekchar]

They had lost most of their volume to the academic center. The program was losing money, and now the hospital is bleeding money. They won’t be the last to be terminated and I expect our hospital to lose its independence by the end of the year.

Rough geographic location?

 

[ChiDO]

Our hospital is still running at basically 50%, having cut out all totally "elective" cases. ~230 cases a week the past couple weeks. Amazing what our reduced case load is like.

That's a **** load of cases. We have barely any COVID patients in house and yet we do maybe 20 cases in each hospital. We've cancelled over 700 elective cases in our PP Ortho group.

 

[dabears505]

Never thought I would see the day when a spine surgeon gets fired when he hasn't killed 100 people.

 

[abolt18]

That's a **** load of cases. We have barely any COVID patients in house and yet we do maybe 20 cases in each hospital. We've cancelled over 700 elective cases in our PP Ortho group.

Tell me about it!

 

[deleted697535]

Were still doing a lot of cases. Probably 20 rooms tomorrow but that's still only half.

Each room only does 2 or 3 cases max tho.
Lots of cancer, ortho, vasc, hearts. They never stop.
were gonna be locked down at this or less until June 30 at least. No plans to ramp back up yet.

So many whinger colleagues Co about dying and stuff

 

[kmurp]

Rough geographic location?

I don’t know the answer to that. I do think that the financial stress of this pandemic will weed out many weak companies. That would likely include many hospitals and poorly performing lines of service at others. I also suspect that paying employed physicians at historical MGMA rates will be a challenge.

 

[AdmiralChz]

Each hospital is pretty different right now for us (southeast PP, not heavily hit with COVID yet). Our academic hospital is probably only down 50 or so % as it’s a large percentage of cancer surgery that can’t really wait. The heart program is basically shut down, and my colleagues who are 100% cardiac are nearly all furloughed. When people ask me why I didn’t join that group, I’ll point there.

At our 2 other hospitals it is very different. One community hospital is at around 30% (large orthopedic joint program on hold), the other is even worse maybe 15-20%. Our ASCs are currently closed (urgent cases being done at the main OR). No office work of course. Many of my partners are called off each day.

These hospitals are part of a large conglomerate but are absolutely biting their nails about how long this will go on. The IHME data has revised the death toll and ICU beds needed down 70% in my state over the last week. There was a plan in place to grant us emergency privileges as intensivists but there is now a question of whether that will even be needed.

All that being said, we won’t be going out on a limb to figure out how to restart the ORs by ourselves. Being suburban we will wait for how other academic centers return to normal.

 

[physicsnerd42]

We are still only doing emergency and urgent cases, though the early shelter-in-place order seems to have really helped with Covid growth being linear instead of exponential. We should have excess capacity in the ICU and floors.

My (children’s) hospital has started testing every patient prior to surgery with a result required prior to anesthesia (except in emergencies). Outpatients are swabbed 2 days prior, inpatients one day prior, and we have a 45 minute test for emergencies. We do not have plans to do elective cases as far as I know, but hopefully they are planning for when the relevant orders stopping elective surgery are lifted.


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[nimbus]

Anybody else have blood shortages?

 

[AdmiralChz]

Anybody else have blood shortages?

With our cardiac and transplant programs basically shut down, we actually are doing great on blood products as of a conference call yesterday.

About 2 weeks ago I was getting cold called by the Red Cross to donate but I was unable to donate. Haven’t gotten any such calls since...

 

[caligas]

Well, the person approving "urgent" cases is a gyn-onc surgeon so all of these cancer surgeries keep happening. Even the laryngectomy w flapthat takes all day and requires that EVERYONE in the OR wear full PPE. EGD for NG placement in 89yo demented woman who doesn't want the NG. Classic.

for the love of Pete cant they get a negative test before the 10 hour ENT case?

 

[deleted875186]

It’s unclear how meaningful a negative test is, still likely a high number of false negatives. We really need a reliable serology test to start ramping up cases I think.

 

[ChiDO]

OK to resume outpatient elective surgery per briefing

 

[AdmiralChz]

OK to resume outpatient elective surgery per briefing

With Phase 1 activation which will vary across states based on outbreak levels. And only outpatient, not inpatient and try to avoid cases where postoperative ventilation will be required - cardiac surgery will be on hold for quite a while.

Our hospital system is convening an emergency meeting tomorrow to discuss how and when Tier 2 cases will be allowed back on the schedule. Could be as soon as next week.

 

[kmurp]

Meanwhile in NY, Cuomo announces electives can resume tomorrow but still no guidance from health dept now 14hrs from the supposed start time.

 

[BLADEMDA]

Are you going to require a negative Covid 19 test prior to doing an elective, outpatient case? For example, an ASA 1 23 year old for an inguinal hernia repair. NO symptoms. Does he/she need a negative test to get a GA with LMA? Are any of you going to use an N95 mask for this case?

FYI, I have read the suggested guidelines from the American College of Surgeons. I am asking you what you will require to do the case.

 

[Southpaw]

Meanwhile in NY, Cuomo announces electives can resume tomorrow but still no guidance from health dept now 14hrs from the supposed start time.

Whoa

 

[Gas]

Are you going to require a negative Covid 19 test prior to doing an elective, outpatient case? For example, an ASA 1 23 year old for an inguinal hernia repair. NO symptoms. Does he/she need a negative test to get a GA with LMA? Are any of you going to use an N95 mask for this case?

FYI, I have read the suggested guidelines from the American College of Surgeons. I am asking you what you will require to do the case.

Meeting with administration tomorrow. We are going to request testing for all elective patients, but then agree to testing only for general anesthesia cases. Everything is a negotiation. Test can be day of (ideally), or if we run low on those, within 24-48 hrs (open to discussion). Will use N95, faceshield, gown for all GA cases. Regular mask for MAC/regional.

Question of what to do if you get a negative test? Still N95? I've heard false negative rates of 30%. I don't know the answer to that one yet. Some of my more cautious partners will do the N95 anyway.

 

[AMEHigh]

Meanwhile in NY, Cuomo announces electives can resume tomorrow but still no guidance from health dept now 14hrs from the supposed start time.

This gives a summary:

Amid Ongoing COVID-19 Pandemic, Governor Cuomo Announces Elective Outpatient Treatment Can Resume in Counties and Hospitals Without Significant Risk of COVID-19 Surge Starting Next Week

Amid the ongoing COVID-19 pandemic, Governor Cuomo announced elective outpatient treatments can resume in counties and hospitals without significant risk of COVID-19 surge in the near term.

www.governor.ny.gov

 

[AMEHigh]

Meeting with administration tomorrow. We are going to request testing for all elective patients, but then agree to testing only for general anesthesia cases. Everything is a negotiation. Test can be day of (ideally), or if we run low on those, within 24-48 hrs (open to discussion). Will use N95, faceshield, gown for all GA cases. Regular mask for MAC/regional.

Question of what to do if you get a negative test? Still N95? I've heard false negative rates of 30%. I don't know the answer to that one yet. Some of my more cautious partners will do the N95 anyway.

Where I am doing outpatient procedures with propofol anesthesia has been wearing N95. We’re not testing, but everyone has to be asymptomatic and we’re checking temps. So presumably many/ most of the patients are negative and anesthesia has still been wearing n95. I’ve just been wearing surgical mask since I’m nowhere near the face and the patient also wears surgical mask.

Edit: I wouldn’t trust a negative test since there are false negatives

 

[kmurp]

Regarding testing: we await NY guidance / requirements. Our Hospital plans on testing all (timeframe TBD), as they have a supply of tests. The ASC: we aren’t sure. If it’s required we will have to test but aren’t sure if our Preop patients can access tests that easily As supply is still spotty and I’m not sure if the hospitals will be willing to share.
Regarding PPE, we will go with the CMS guidelines that emphasize PPE for aerosolizing procedures and, in addition, will likely have other staff exit the room for intubation/extubation per the non covid guidelines of our local academic center.

 

[dannyboy1]

Prop. Roc. Tube.

 

[nimbus]

Meeting with administration tomorrow. We are going to request testing for all elective patients, but then agree to testing only for general anesthesia cases. Everything is a negotiation. Test can be day of (ideally), or if we run low on those, within 24-48 hrs (open to discussion). Will use N95, faceshield, gown for all GA cases. Regular mask for MAC/regional.

Question of what to do if you get a negative test? Still N95? I've heard false negative rates of 30%. I don't know the answer to that one yet. Some of my more cautious partners will do the N95 anyway.

Positive test is very helpful. Negative test is not very helpful because there is a high rate of false negatives. I wear an N95 while I’m at work. I only take it off when I eat or drink, otherwise it’s on my face.

Asymptomatic SARS-CoV-2 Infection in Household Contacts of a Healthcare Provider, Wuhan, China

Asymptomatic SARS-CoV-2 Infection in Household Contacts of a Healthcare Provider, Wuhan, China

wwwnc.cdc.gov

 

[deleted875186]

Depends on the proportion of Covid in your area. Even if your a skeptic of the PCR test and believe it has a 70% sensitivity, the negative predictive value might still be very high if there’s an overall low prevalence of the disease.

Certainly a negative test in NYC, Boston, Chicago, Michigan right now is less meaningful than a negative test in North Dakota.

 

[Shimmy8]

Starting Monday Phase 1. Elective cases under 70 yo.

Negotiating with hospital now about testing. False negatives are a big sticking point. We’re in an area not hit too hard, I’m sure some admin are trying to save cash and PAT time.

For next little bit will likely wear N95, faceshield, and gown for GA cases.

 

[dannyboy1]

Depends on the proportion of Covid in your area. Even if your a skeptic of the PCR test and believe it has a 70% sensitivity, the negative predictive value might still be very high if there’s an overall low prevalence of the disease.

Certainly a negative test in NYC, Boston, Chicago, Michigan right now is less meaningful than a negative test in North Dakota.

No it is not. If the “negative predictive value “ is high because of low prevalence it just means it’s a $hitty test but probably right because the vast majority of the population in question does not have the disease. So why get hung up on testing?

 

[deleted875186]

No it is not. If the “negative predictive value “ is high because of low prevalence it just means it’s a $hitty test but probably right because the vast majority of the population in question does not have the disease. So why get hung up on testing?

That’s exactly what it means.
It also means that a false negative test will be extremely rare.

You’re debating if the cost of the test is worth it. Currently it’s the only widely available test we have. I would argue it’s certainly better than no test.

 

[Justice4all]

peds here. ideally testing 2-3 days before the case and rapid testing on DOS for all elective cases. If negative, then no N95. For trauma or emergencies , full covid precautions.

 

[ChiDO]

Resumed elective total joints at our surgery center and non-icu small hospital this week at small/min volume. All patients getting COVID testing prior. Increasing volume weekly over 4 weeks until 100%.

One hospital system is letting people be scheduled mid May at half volume. The other has lifted restrictions and opened more ORs, but probably not letting elective joints till June.

I wear a N95 under my Ortho hood during sx.

 

[apoondoc]

Here are the requirements I received from an HCA hospital (where I worked 3+ years ago). Apologies if I don't scrub all the incriminating information:



Dear Physicians and Providers,

We are pleased to announce that ***** Hospital is now accepting the scheduling of surgical cases for a start date of May 4th.

Our staff, physician partners and patients' safety comes first.

Patient safety has always been our top priority. As we prepare to open our doors to resume routine patient care services, we are intensifying our already rigorous protocols and precautions to keep your patients safe. Our goal is to reassure patients that they can safely return to our care environments for testing, procedures, surgery, and other critical services.

Elective procedures have been classified within tiers of urgency and acuity allowing for prioritization of surgeries during the pandemic.

Tiers 1-3 are now approved to be scheduled including but not limited to:


· CABG, Cardiac EP & Other Cardiac Surgeries

· Orthopedic Surgeries

· Brain & Spine Surgeries

· General Surgery Cases

· Oral/Maxillofacial Procedures

· GI Procedures

· General Gynecologic Surgeries

· Women’s Reproductive Procedures

· Urologic Procedures & Surgeries



What we’re doing to make sure patients are COVERED


· To assist in scheduling new elective cases as well as those that were previously approved and canceled due to COVID-19, please call*******and the Scheduling Team is now able to book your appointment and answer any questions you may have in advance.

· To aid your patients during this time, Patient Benefit Advisors will help patients navigate insurance options as well as payment concerns once their surgery is scheduled.



What we’re doing to make sure you and your patients are SECURE


· Increased COVID-19 Testing. Surgical patients are required to test within 72 hours of their scheduled surgery date.

· Physical distancing. This will be required at all times for all visitors, staff and patients.

· Temperature checks. All employees will have temperature checks before they enter the hospital.

· Employees and face masks. All employees must wear face masks.

· Face masks for patients and visitors. All patients and visitors who don’t show symptoms must wear face masks.

· Entrances. There is an established entrance for well patients having scheduled and elective procedures.

· Separate areas for patient care. These are for normal, routine procedures.

· Physical distancing among staff. There will be a limited number of hospital staff in each room at one time.

· Visitor policies. We will make sure to maintain physical distancing in these ways:

o One visitor will be permitted to accompany each patient after being screened, receiving a temperature check and given a face mask. Exceptions to the one visitor policy will be reviewed on a case-by-case basis.

o Visitors who screen positive for flu or COVID-19 will not be able to visit a patient. Exceptions will be made for: 1) an end-of-life situation or 2) a family member or guardian who must make a medical decision.

o If a visitor screens positive for a communicable disease and must enter the facility, the visitor will be escorted.



What we’re doing to keep you and your patients SAFE


In the operating room

· All ORs are cleaned after every surgery.

· Every OR has a deep cleaning every night on all surfaces. This process:

o Removes every item in a room that can be detached and then disinfects it.

o Cleans light fixtures, air ducts and all surfaces from the ceiling to the floor.



In other patient care areas, including cardiac cath lab, inpatient rehabilitation, and endoscopy

· Deep cleaning is done frequently on all surfaces and in every area.



In public areas (including restrooms and waiting rooms)

· Deep cleaning is done frequently on all surfaces and in every area. This process:

· Removes every item in a room that can be detached and then disinfects it.

· Cleans light fixtures, air ducts and all surfaces from the ceiling to the floor.

· Testing all through the day to spot viruses or bacteria that may be present.

· This will help us make sure to keep surfaces clean and safe.

· Common areas have been modified as well to adhere to infection control policies.