When Can We Open for Elective Surgeries?

John Whyte, MD, MPH; Valerie Rusch, MD


May 08, 2020

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  • Before opening for elective surgeries, the incidence and prevalence of COVID-19 in the community and hospital, hospital resources, the urgency of the surgery, and the ability to do COVID testing must be taken into consideration.

  • Having a multidisciplinary committee, including surgeons, anesthesiologists, nurses, and administrative staff, is extremely important.

  • Surgeons can address patient frustrations by having a conversation with each patient to communicate that they're trying to do what's safest for that patient.

  • Surgeons and hospitals will have to exercise flexibility over the coming months to accommodate the needs of patients, such as extending the hours or number of days that they operate.

This transcript has been edited for clarity.

John Whyte, MD, MPH: You're watching Coronavirus in Context. I'm Dr John Whyte, chief medical officer at WebMD. My guest today is Dr Valerie Rusch, president of the American College of Surgeons. Dr Rusch, thanks for joining me.

Valerie Rusch, MD: My pleasure. Thank you.

Whyte: Elective surgery has been on everyone's mind. And people are wondering—as the economy starts to reopen, as society starts to reopen—when they might start thinking about having their surgery.

Rusch: I think this needs to happen in a measured, incremental way that preserves the safety of patients as well as the safety of hospital staff. Now, that's not going to happen to the same degree in every geographic location. The joint statement issued by the American College of Surgeons, American Society of Anesthesiologists, Association of periOperative Registered Nurses, and American Hospital Association, as well as a more detailed document from the American College of Surgeons last week, really provides a template for moving back toward a full elective surgery schedule.

Whyte: Can you walk us through what that template might look like?

Rusch: To start, you have to take into consideration the incidence and prevalence of COVID-19 in your community as well as in your hospital. For instance, it's not even uniform across New York City, obviously; there are some parts of the city that have been more heavily affected than others.

You have to take into consideration the hospital resources that are available to perform surgery in a safe and effective manner: Do you have the equipment? Do you have the personnel? What are the abilities to do COVID testing to make sure that patients enter the hospital COVID-free? What are the possibilities for COVID testing of staff to make sure that the perioperative environment for the patient is safe, etc.?

Those documents don't provide a fixed timeline or a fixed guideline, but they do provide a structure and a template for hospitals and surgeons to follow as they consider how to go about doing this.

Whyte: Is your sense that some communities may start to reopen and be able to do more elective surgery, with those caveats that you just mentioned?

Rusch: Yes, I do think so. In my own hospital—Memorial Sloan Kettering, here in the city—we take care of cancer patients. And most of the operations that we do are not strictly elective. There are varying degrees of urgency, and that is another factor to be taken into consideration.

One point that's made in these documents is the extreme importance of having a multidisciplinary committee or group of individuals—from the surgical side, the anesthesiology side, the nursing side, and the administrative side—to look very carefully each day at the operating room schedule to try to make sure that the ramp-up is prioritizing patients who need to have surgery most urgently, and that the hospital can accommodate and care for them safely in the perioperative setting.

Whyte: How do we address the frustration of patients who may say, "Dr Rusch, I need a knee replacement because I have chronic pain, which is debilitating"? And other folks who have cataracts who are saying, "This is impacting my quality of life"? They're weighing their risks versus benefits, but they're not the decider in terms of whether a surgery can proceed.

How do we address some of those frustrations? We use the word "elective," but for many patients, that may not be the best term. So how do we help address some of those frustrations?

Rusch: I've had these very conversations with each of my patients. In fact, here at Sloan Kettering, we have a backlog for the past 4-6 weeks of over 1000 patients. Those are 1000 cancer patients, despite being very, very careful about trying to prioritize who has the most urgent situation. And really, the conversation is around "Do you have a life-limiting problem? Do you have a problem that is severely limiting your quality of life? Are we able to care for you safely?"

Because the worst thing we could do for patients would be to have them come in for a relatively elective operation and actually be exposed to COVID and become COVID-positive. And then, of course, their risk for severe complications or even not making it out of the hospital becomes greater because they're recovering from a major operation.

So I think that each surgeon has to have that conversation with each one of their patients and try to weigh the risks and benefits, and explain to the patient that we're trying to do what's absolutely the safest for them as an individual patient.

Whyte: Does it differ in outpatient surgical centers if I can go to an ambulatory surgical center versus having to go to the hospital? Is there less risk at certain types of centers and clinics?

Rusch: There may be. And again, that's going to be a little bit individual, depending on the institution and the circumstances. Certainly, if it's a completely ambulatory procedure or maybe a 23-hour-stay type of facility, that may be associated with a reduced risk.

But there's still a need to make sure that patients and staff are COVID-free and that we're functioning in the safest possible environment. At Memorial Sloan Kettering, we're doing preoperative COVID testing within 48 hours. It doesn't matter whether you're having an outpatient procedure, a short stay, or a hospital-based stay.

Whyte: How are we going to make up these 1000 surgeries at your institution that have been delayed? I'm sure that's the case at many other centers around the country. Where are we going to be 6 months from now, do you think?

Rusch: We're going to have to exercise some flexibility over the coming months to accommodate the needs of our patients. That may be extending the number of days. I happen to function in an institution where we operate routinely on Saturdays, but that's probably the exception to the rule for most hospitals. We're probably going to have to extend hours in the operating room, the number of days that we operate, and so forth, and just be flexible about that, but all in the context of making sure that we have sufficient supplies, sufficient staff, and that we have the safest possible environment.

Whyte: And what type of financial impact has the cancellation of elective surgery caused to many of these institutions? There's been talk that it's really hampering the ability to function.

Rusch: There's no question that this is going to have a severe impact on many aspects of our healthcare system. Some hospitals, larger institutions, have figured out ways to stay afloat and be somewhat buffered from the economic consequences, at least in the short term.

But perhaps the most concerning areas are geographic regions where there are so-called "critical access hospitals." These are usually smaller, more rural communities where the local hospital is sustained by elective surgical volume and doesn't really have the wherewithal to manage this time of crisis and complete cessation of elective cases. So I think we're going to see some communities really, really suffer from what's happened here.

Whyte: For patients who want to consider surgery, assuming it's not emergent, what should they do right now? Should they contact their physician? Should they wait a couple of weeks? Should they look online and see what's happening in their area with COVID? What recommendations would you have for a patient?

Rusch: The first and foremost approach is for that patient to have a direct conversation with their surgeon, if they already presumably have a surgeon, and to explore with that physician the hospital circumstances and the safety issues associated with them potentially undergoing a procedure.

Whyte: Dr Valerie Rusch, president of the American College of Surgeons, I want to thank you for your time today.

Rusch: Thank you so much. A pleasure to speak with you.

Whyte: And I want to thank you for watching Coronavirus in Context. I'm Dr John Whyte.

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