The Return of Elective Surgery

The Covid-19 crisis is not behind us, but it seems the first (and hopefully only) wave of infections is waning in certain areas of the U.S. and in some parts of the world.

So it’s no surprise there’s a push for things to get back to “normal.” That normal includes elective surgery, which was an early casualty of the novel coronavirus. 

At the beginning of the outbreak, there were fears that a lack of PPE, ventilators and ICU beds would overwhelm doctors and hospitals and elective surgery was pushed down the list of priorities.  

While this scenario, in which operating rooms were converted into makeshift ICU rooms for COVID-19 patients, was necessary in coronavirus hotspots, it wasn’t the case everywhere and as Forbes observes, “Other [hospitals], in cities and smaller towns less dramatically hit with this pandemic, were left with quiet operating rooms as well as quiet ICU’s.”

The Roadmap to returning to regular elective surgery

While President Trump has tasked each governor with deciding the timeline for opening up each state, the American College of Surgeons, the American Society of Anesthesiologists, the Association of periOperative Registered Nurses and the American Hospital Association have created a “Roadmap” detailing when and how elective surgeries should restart.  

Among the criteria the Roadmap lays down is that the rate of new COVID-19 cases in an area must have dropped substantially for at least 14 days before elective surgery can begin again. 

Supporting this criteria, the Ambulatory Surgery Center Association issued a statement to support the return to elective surgery saying, “The reality is that regions across the nation are impacted by COVID-19 to varying degrees. There are some communities that are ready for a strategic restart of deferred healthcare at this time, while continuing to focus on limiting COVID-19 spread.”

But flattening the curve on new cases is not enough. In addition, facilities must ensure they have the appropriate number of ICU and non-ICU beds, PPE, ventilators and trained staff to treat all non-elective surgery patients without resorting to what it terms, a crisis standard of care.”

As of May 13, approximately 26 states had resumed some elective surgeries, with a handful more planning to do so in the coming weeks. It still cannot be predicted when surgery will be restarted nationwide.

Elective surgery worldwide

In countries that have flattened the Covid-19 curve, elective surgery is gradually resuming as governments ease lockdowns. Among the countries seeing a return to the OR are those that took strict measures early on and flattened the curve quickly compared to other parts of the world.

Australia   

Australia resumed some elective surgery procedures from April 27. These include IVF, post-cancer reconstruction procedures, joint replacements, eye procedures, endoscopy, colonoscopy and procedures for any patients under the age of 18. This amounts to about a 25% resumption of elective surgery in both public and private hospitals.

The desire to return to operating is not only for health benefits, but also motivated by financial losses – a factor also, no doubt, relevant to the U.S. According to this article, US hospitals are losing around $50 billion a month due to Covid-19. So too in Australia, dozens of private hospitals across the country warned they would be forced to close due to losses accrued from the ban on elective surgeries. 

New Zealand   

With a strict lockdown from the get-go, New Zealand was lightly hit by Covid-19. As the country moves to reduce some of its measures, the New Zealand Herald reported that some of the 30,000 postponed elective surgery procedures have restarted.

The New Zealand Herald also reported that medical experts say now is the time to “get on with it” and clear the backlog of tens of thousands of surgeries put off under lockdown.

Israel   

In Israel, where action was taken early to prevent the spread of Covid-19, many lockdown measures have now been loosened, and elective surgery restarted on May 3. Interestingly, an article in the Times of Israel reported that death rates in March, when elective surgery was halted, declined by 12 percent compared to the previous year and saw a five-percent drop compared to the average monthly rate (4,066) from the past decade.

This is not the first time Israel has seen such a phenomenon. “Our experience from similar situations in which elective procedures [were canceled], primarily over doctors’ strikes and wars, shows that these cancellations cause a drop in death rates in the short term, because many people die from infections while hospitalized, after undergoing surgery or invasive testing,” said Prof. Nadav Davidovitch of Ben Gurion University, an epidemiologist and public health expert.

However, he added that in the long term, many more will die because of delaying these treatments, which is one reason governments and healthcare providers are eager to restart elective surgery.

“Many more will die because of delaying these treatments, which is one reason governments and healthcare providers are eager to restart elective surgery.”

Canada   

Like the U.S., Canada is dealing with an uneven distribution of Covid-19 cases across its provinces, with the majority of cases and deaths centered around Quebec. Elective surgeries have already resumed in Alberta, Manitoba, New Brunswick and Prince Edward Island, with hospitals and healthcare providers in British Columbia planning to restart in mid-May. No date has yet been announced for the resumption of surgery in Ontario or Quebec, leaving thousands of patients in the dark about just when they might finally have their operations.

According to CTV News, elective surgical services are expected to resume on May 18, but officials say it could take over a year for the country’s healthcare system to clear the backlog.

It will take time to return to any level of ‘normalcy’ – including in the OR 

While more and more U.S. states are opening up and restarting elective surgery, the return to regular scheduling will take some time. From the perspective of surgeons and hospitals, the issue is how to decide which patients to prioritize. With many areas still yet to open up, this is the best time to get processes and priorities in place to ensure a smooth transition and efficient rescheduling process. Even once elective surgery resumes, the backlog will linger for months, possibly years, so the prioritization process will need to be a new part of any surgery practice’s workflow. 

From the patients’ perspective, feeling secure enough to come into a hospital will also take time. “They are afraid of coming in because of the virus. We have a huge consumer confidence problem,” said Rob Casalou, CEO of Trinity Health Michigan, which found that only 10% of the patients it contacted about rescheduling surgery gave the go ahead for their procedures. 

Hopefully, that confidence will return soon, and so will elective surgery nationwide. Even with the break of just a couple of months, the world will be living with the effects of postponing elective surgery for the next year, and that’s before the threat of a second wave.