Returning to the 'New Normal': Handling the Backlog of Elective Surgeries

Interviewer: Lara C. Pullen, PhD; Interviewee: Bryan T. Kelly, MD

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July 31, 2020

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When the coronavirus pandemic hit New York City mid-March, elective procedures were halted in many hospitals and ambulatory surgery centers. By late April, 36 additional states barred elective procedures. Orthopedic surgeons were deeply affected by the ban: Many of them lost 95% or more of their patient volume, and some closed down their practices temporarily.

Bryan T. Kelly, MD

Lara C. Pullen, PhD, recently spoke with Bryan T. Kelly, MD, to find out how this ban affected him and his colleagues, and his experience in resuming elective procedures at Hospital for Special Surgery (HSS). He is surgeon-in-chief and medical director at HSS and a professor of orthopedic surgery at NewYork-Presbyterian Weill Cornell Medical College in New York, NY.

Can you briefly describe what was it like in New York City then and now?

The outbreak was an unprecedented test of the New York City healthcare ecosystem. HSS turned into the storm by voluntarily suspending all but the most urgent orthopedic surgeries and transforming within days into a multispecialty hospital treating overflow patients from neighboring providers.

To treat critical care and urgent medical surgery patients, we converted operating rooms into intensive care units (ICUs) and anesthesia machines into ventilators, and hundreds of frontline staff adapted to meet unimaginable challenges.

When our number of newly hospitalized patients with COVID started trending downward, we were able to rapidly discharge patients or transfer them back to other hospitals that had more equipped ICUs, ICU nursing staff, and critical care doctors. We then conducted terminal cleaning and rebuilt, and we are now on an accelerated return to a "new normal."

All things considered, and given where we were with COVID-19 a few months ago, things are going really well.

Have you resumed orthopedic surgeries?

We never stopped providing emergent orthopedic surgeries and conducted a process to define "essential" and other classifications of care. We prioritized emergency surgeries that needed to be done within 24-48 hours, urgent surgeries within 4-6 weeks, and priority surgeries within 12 weeks of the diagnosis and the predetermined treatment plan.

On May 6, we reached the point that it became responsible to expand care to include urgent orthopedics.

The biggest challenge for us is that we had a backlog of approximately 6000 surgeries that were suspended for a 7-week period. I think it's going to take 3-4 months to get through this backlog. We typically do somewhere around 130-140 orthopedic surgeries a day here. We're currently operating at around 75% capacity.

More ambulatory surgery is occurring, and we're now seeing is a significantly shorter length of stay. Patients who have a total joint replacement, where you might have expected a 2- or 3-night hospital stay, are discharged on the same day. I think that's great for the patient. It's something that there has been momentum in healthcare to do that anyway, to reduce length of stay.

One of the major issues is discharging older patients to skilled nursing facilities. We're trying to maximize care, reduce length of stay, and send patients home where they receive home healthcare rather than send them to skilled nursing facilities.

Are you using telemedicine more?

We ramped up telemedicine at an exponential rate. We had early experience with it, but we weren't using it in any meaningful capacity before the pandemic. We're now doing over 1000 telemedicine visits a day. There's lots of things that we're learning you can do more effectively virtually, and it's more convenient for the patient.

There are some challenges to telemedicine, such as the limitation in performing a physical exam. We all feel a little bit uncomfortable about booking a patient for a surgery without having yet seen them in person, and there are challenges with licensing. Despite some leniency in the licensure rules, if you're not licensed in the state agency, you can't see a new patient through telemedicine.

Historically, many of our patients have come from outside the tristate area. Although telemedicine doesn't allow access to all the people that we would typically treat, it creates access and convenience for many more area residents.

Do you use a database to track whether outcomes differ since the pandemic?

We're tracking all postoperative patients for 90 days with regular follow-ups. The early data that we have is on the spine surgeries that were done during the height of the pandemic. They were performed in an emergent fashion, and there was no significant increase in postoperative complications relative to complications in the non-COVID environment. It's encouraging, but there's a lot that we still don't know.

Are you finding that patients are voluntarily deferring surgery?

There's a lot of evidence that a significant number of consumers remain apprehensive about nonurgent surgery in New York City. Our patient volume is ahead of our projections as recently as May, but below typical volume ─ partly because of capacity limitations related to safety, but also because some patients are deferring surgery. We anticipate that volume will decline as we get through the backlog.

What do you think is contributing to patient hesitancy?

Some of it is just making sure patients living outside of New York City know we're open for elective surgeries. Many people still think of New York as the nuclear fallout zone. Right now, our hospital is one of the safest places to be in the city, because we spent such extensive efforts in cleaning, testing, and screening. It would have to be a true orthopedic emergency (ie, an open fracture or something similar) for a procedure to be performed on a patient who tests positive for COVID.

Do you have an adequate supply of COVID tests at your hospital?

It's always in the back of our minds as a concern, but it's not been a barrier for us being able to do surgery. We do in-house testing, and it's about a 53-minute turnaround.

The CDC has relaxed their guidelines, and they now allow testing within 5 days before surgery (after a period of self-quarantine and an initial negative test). When you have 35 operating rooms and procedures are supposed to start at 7:30 or 8:00 AM and you're waiting for 35 viral test swabs to come back, it creates a bit of pressure in the system.

How do you reach out to patients and let them know that this process is safe and the outcomes are good?

In the context of COVID, the HSS website is populated with a lot of safety and educational materials for patients. We also have an informed consent statement ─ an attestation that the surgeon has spoken with the patient regarding COVID and informed them of all safety measures that we put in place. One of the nice things about our hospital is we do have a reputation and a history of being an extremely safe place to have your surgery with a very low complication rate, and a very low infection rate.

In our outpatient department, we're limiting the number of patients per hour. It's the first time you can go to the doctor without having to wait for the doctor. We have also made changes and optimized our overall surgical schedule. In the past 3 months and in the middle of the pandemic, we had time to think about ways we can improve operational efficiencies related to surgeries.

HSS is a large teaching institution. Did you postpone the training of orthopedic surgeons during the COVID crisis, or were you still able to do some of that virtually?

On the orthopedic side, we have 11 different subspecialty services, each with an educational program that is dedicated to resident and fellow teaching. During the COVID surge, we were operating at 10% capacity. There was a significant reduction in hands-on surgical training and more didactic teaching.

However, the residents and the fellows received a unique education, one they will remember for the rest of their lives. They actively participated in the care of all of the patients that were hospitalized during the pandemic.

Any final thoughts?

What I've encountered is that it's easier to turn an orthopedic hospital into a COVID hospital than turn a COVID hospital back into this orthopedic hospital. There's a little bit more brute force in turning into a COVID hospital ─ so many nuances in trying to make sure that patients are entering as safe of an environment as possible. It's extremely detail-oriented, and HSS has done a great job at paying attention to all of those. We'll continue to push forward, and hopefully we'll be back to 100% soon.

What if there is another surge in the fall?

We have a whole COVID playbook now. We learned from the crisis what we did well, and what we need to do better. If a surge does occur, all of New York City and all hospitals will be prepared.

The one thing that was most amazing about the crisis was the collaboration that you saw, not only within the hospital but within the New York City hospital systems. There was a real joint effort, even with competitive institutions, of everyone working together to help everybody. It was great to see it.

Lara C. Pullen, PhD, is a medical writer based in the Chicago area.

Bryan T. Kelly, MD, is surgeon-in-chief and medical director at Hospital for Special Surgery, and a professor of orthopedic surgery at NewYork-Presbyterian Weill Cornell Medical College in New York. Kelly is chief emeritus of the Sports Medicine Institute and served as co-director for the Center for Hip Preservation. He specializes in sports medicine injuries and arthroscopic and open surgical management of nonarthritic disorders around the hip. 

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