Tufts Medical Center in Massachusetts started calling patients earlier this week to reschedule elective procedures, such as knee and hip replacements and even annual physical exams, so it could prepare for an influx of patients with coronavirus.
“As we began to see that we were going to face a significant issue with the pandemic, we started to look at what we could do to slow down the cases with social distancing,” explained the health system’s CEO Michael Apkon by phone.
“We also saw a reality of limited stock, including personal protective equipment, across the industry,” he continued. Another concern for the hospital, according to Dr. Apkon, was making space for more coronavirus patients. Many of the elective procedures underway could require a patient to remain in the hospital for up to five days, and the situation could take a turn for the worse in that time.
“We operate close to the limit on a good day,” he said, referring to the hospital’s intensive care unit capacity.
As of this week, coronavirus cases in the U.S. have climbed to more than 2,000 people. The number is expected to spike higher still, as testing becomes more widespread.
Hospitals in the U.S. are facing mounting pressure to stop performing elective and non-urgent procedures, which represent a major chunk of their annual revenues. Public health officials fear that if these surgeries continue, they’ll sap important supplies and resources that might be needed for the most serious coronavirus cases. There’s also a concern that at-risk seniors could come into the hospital for a procedure they don’t immediately need, instead of isolating themselves at home, increasing the chances of getting sick.
“My preference is they (hospitals) cancel aggressively now,” said Andy Slavitt, the former administrator of the Centers for Medicare and Medicaid Service during the Obama Administration. “If not, I hope they start to cancel as things ramp so they don’t clog other parts of the system like ICU beds and use up supplies.”
“Each hospital, health system, and surgeon should thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations, endoscopies, or other invasive procedures until we have passed the predicted inflection point in the exposure graph,” suggests the American College of Surgeons. The Centers for Disease Prevention and Control has issued even stronger guidance in regions hit hard by the coronavirus, including Santa Clara County, specifically stating that hospitals “cancel elective and non-urgent procedures.”
Business as usual for some
But for many hospitals, it’s business as usual -- at least for now.
The decision to delay or cancel cases is a particularly difficult one for cash-strapped hospitals, health experts say. The procedures represent a major source of funds for health systems, and are often given priority over emergency surgeries. A recent analysis shows that hospitals earn about $700 more on each elective admission than on each patient admitted through the emergency department.
“Yes I’m concerned about the finances,” said Dr. Apkon, when asked about the hit to health systems. “But the financial impact for what we’re going through with a slowdown in our clinic pales in comparison to the broader impact that this pandemic will have.”
Sutter Health, in the San Francisco Bay Area, confirmed it hasn’t yet canceled elective surgeries.
Some are taking more tentative steps than issuing sweeping cancellations. Dr. Jeffrey Swisher, chairman of the department of anesthesiology at California Pacific Medical Center, said many hospitals including his own have “algorithms in place” to guide decision-making. This technology, Dr. Swisher said, can help to determine if and when to delay or cancel elective procedures depending on factors like the number of coronavirus cases and the rate of patients coming into the hospital.
Other health systems have convened a panel of human experts to help them figure out what to do. At UC San Francisco, some non-urgent elective surgical cases have already been cancelled. But going forward, a spokesperson said, “we have a vetting process which includes surgical chairs and peri-operative leadership to assure that the most urgent cases go forward.”
Procedures most likely to be postponed are those that require patients to remain in intensive care units or on ventilators for several days, suggests Mudit Garg, the CEO of Qventus, a company that works with health systems to understand their operations.
Garg’s company recently developed a data visualization that incorporated a variety of data sources to map out the biggest projected supply chain gaps. If the coronavirus continues to spread, he expects that the many hospitals could run out of vital medical equipment and other supplies quickly in some states. There might also be challenges transferring patients from smaller, more rural hospitals to larger ones.
“For many hospitals it hasn’t gotten to the point yet where they need to cancel altogether,” said Garg. “But they need to be prepared to make that call quickly.”