Abstract
Background:
The SARS-CoV-2 (COVID-19) pandemic has resulted in widespread cancellation of elective orthopaedic procedures. The guidance coming from multiple sources frequently has been difficult to assimilate as well as dynamic, with constantly changing standards. We seek to communicate the current guidelines published by each state, to discuss the impact of these guidelines on orthopaedic surgery, and to provide the general framework used to determine which procedures have been postponed at our institution.
Methods:
An internet search was used to identify published state guidelines regarding the cancellation of elective procedures, with a publication cutoff of March 24, 2020, 5:00 p.m. Eastern Daylight Time. Data collected included the number of states providing guidance to cancel elective procedures and which states provided specific guidance in determining which procedures should continue being performed as well as to orthopaedic-specific guidance.
Results:
Thirty states published guidance regarding the discontinuation of elective procedures, and 16 states provided a definition of “elective” procedures or specific guidance for determining which procedures should continue to be performed. Only 5 states provided guidelines specifically mentioning orthopaedic surgery; of those, 4 states explicitly allowed for trauma-related procedures and 4 states provided guidance against performing arthroplasty. Ten states provided guidelines allowing for the continuation of oncological procedures.
Conclusions:
Few states have published guidelines specific to orthopaedic surgery during the COVID-19 outbreak, leaving hospital systems and surgeons with the responsibility of balancing the benefits of surgery with the risks to public health.
The SARS-CoV-2 (COVID-19) pandemic has created a substantial strain on the United States health-care system. In anticipation of a surge of infected patients as well as increased demand for personal protective equipment (PPE), on March 13, 2020, the American College of Surgeons (ACS) recommended postponing or canceling elective procedures1. Two days later, the Centers for Medicare & Medicaid Services (CMS) followed that guidance with their own recommendations on approaching elective procedures, comprising a 3-tiered system taking into account both the acuity of the procedure and the underlying health of the patient2. However, vague language has created substantial ambiguity in the interpretation of these guidelines. Understandably, national societies, both in orthopaedic surgery and in other specialties, have yet to come up with their own specific guidelines in this rapidly changing environment. However, many state governments have provided either recommendations or mandates regarding the performance of elective procedures.
This topic is particularly relevant for orthopaedic surgeons as approximately 47% of orthopaedic expenditures come from elective procedures3. It also presents the challenge of determining which operations are truly elective and which operations should continue being performed during this crisis. Additionally, despite guidance, there have been several reports of major academic centers continuing to perform elective procedures as recently as March 21, 20204, potentially because of the plethora of sources providing guidance in addition to the rapidly evolving nature of the outbreak. In light of guidance coming from a variety of sources, we seek to communicate the current guidelines published by each state, to provide discussion on the impact of guidelines on orthopaedic surgery, and to provide the general framework for determining which procedures have been canceled or postponed at our institution.
Materials and Methods
An internet search engine was used to identify guidelines for providers that had been published by their respective states. The cutoff for data collection (i.e., state publications) was set for March 24, 2020, at 5:00 p.m. Eastern Daylight Time. Data were collected on which states had provided guidance regarding the continuation of procedures as well as the form in which the guidance was given (i.e., mandate or recommendation). We also sought to determine whether or not the state had provided a specific definition for “elective” procedures or provided specific guidance in determining which procedures should continue to be performed. Finally, orthopaedic-specific recommendations were recorded.
Results
Of the 50 U.S. states, 30 provided guidance either recommending or mandating the discontinuation of elective procedures5-34. Sixteen states provided a definition for “elective” procedures or specific guidance for determining which procedures should continue to be performed7,8,10,11,13,14,17-19,22,24-27,29,34. Only 5 states provided guidelines that specifically mentioned orthopaedic surgery10,17,18,29,34. Of those 5 states, 4 explicitly allowed for trauma-related procedures10,18,29,34 and 4 provided guidance against performing arthroplasty17,18,29,34. Ten states provided guidelines suggesting that it was appropriate to continue oncological procedures7,8,10,18,19,25-27,29,34.
Discussion
A large number of orthopaedic procedures are elective, and the COVID-19 pandemic will have a substantial impact on our patients’ well-being while also placing a financial burden on hospitals, surgeons, and everyone involved in the care of these patients. National governing bodies have recommended canceling or postponing elective procedures1,2, whereas guidance at the state level has varied substantially.
Twenty states had yet to publish guidance as of March 24, 2020. Furthermore, among the states that did provide guidance, only approximately one-half provided specific guidance to aid in the determination of which procedures should continue and only one-third explicitly mentioned continuing oncological procedures. Even fewer explicitly mentioned that trauma-related procedures should continue or that arthroplasty should be discontinued.
With vague guidance at the state level that rarely mentions orthopaedic surgery, surgeons and hospitals have largely been on their own to determine which procedures should continue to be performed and which should be postponed. However, one source of information that states, hospitals, and surgeons can consult is the CMS tiered approach for surgical services2. Tiers 1, 2, and 3 designate low, intermediate, and high-acuity procedures, respectively, whereas the designations “a” and “b” indicate healthy and unhealthy patients. CMS recommends postponing all Tier-1 operations, to consider postponing Tier-2 operations, and to continue performing Tier-3 operations. Specific orthopaedic operations that are mentioned include carpal tunnel releases (Tier 1a), “hip, knee replacement and elective spine surgery” (Tier 2a), and “most cancers” and “highly symptomatic patients” (Tier 3a). No guidance is provided on what is considered a “highly symptomatic patient.”2 Certainly, patients with carpal tunnel syndrome, osteoarthritis, and other orthopaedic conditions that in normal times necessitate “elective surgery” may have severe symptoms, creating even more ambiguity.
The case of Ohio provides an example of how one state and hospital system handled this ambiguity amidst an unprecedented pandemic. Ohio Governor Mike DeWine issued an order to cancel elective procedures in order to protect patients and providers, preserve critically short supplies of PPE, and preserve inpatient bed capacity and other equipment for critically ill patients25. Following this mandate, in an attempt to provide a consistent approach throughout the state, the Ohio Hospital Association (OHA) developed criteria intended to be used throughout the state for determining which procedures should be canceled. The OHA asked that each hospital and surgery center cancel procedures that did not meet any of the following criteria: “threat to the patient’s life if surgery or procedure is not performed, threat of permanent dysfunction of an extremity or organ system, risk of metastasis or progression of staging, risk of rapidly worsening to severe symptoms (time sensitivity).”35 Our institution determined that it would apply those principles and postpone operations, specifically, those scheduled for the next 30 days, that were not time-sensitive according to this definition.
With that in mind, individual surgical and procedural division directors at our institution developed a list of procedures that should continue to be performed. This list was then approved by respective department chairs before finally being approved by the hospital chief clinical officer. It is important to keep in mind that while the list provided is current as of the time of writing, this list is also likely to change in the future as the demands placed on our hospital system change. The list of orthopaedic procedures that our institution determined should continue to be performed is shown in Table I.
TABLE I.
Procedures Continuing to Be Performed During the COVID-19 Outbreak at Our Institution*
Trauma-Related | Oncological | Infection-Related | Other |
|
|
|
|
List is accurate as of March 25, 2020.
It is important to consider that while the list attempts to be explicit and to create clear distinctions, it is not completely without ambiguity, considering that it includes “select closed fractures that if left untreated for >30 days may lead to loss of function or permanent disability.” The inclusion of this statement makes it necessary for surgeons to make a judgment call and to reconsider typical indications for which fractures necessitate fixation in the short term. It is very likely that in the event that resources become more scarce, surgeons may be required to postpone treatments beyond what we would consider usual. A mechanism for review of scheduled cases is in place at our institution to ensure that patients are getting care that is appropriate to our institutional capabilities. Additionally, as the pandemic evolves, a potential way to further classify procedures is by separating them into 2 categories: (1) those that need to be performed within 2 weeks and (2) those that need to be performed within 4 weeks. This distinction would be helpful as resources become scarce and more clear guidelines are needed.
Guidance regarding the continuation of orthopaedic procedures during the COVID-19 pandemic has come from a variety of organizations and frequently has been vague, putting the onus of decision-making on individual hospital systems as well as surgeons. Ultimately, surgeons must weigh the benefits of performing surgery with the potential impact on public health. While patients wait for surgery, surgeons should provide them information regarding alternative methods of managing their pain36.
Disclaimer
This publication is intended to provide its readers with information regarding the guidelines provided by each state as of the time of writing (March 25, 2020). Additionally, the list of procedures currently being performed at our institution is accurate of as March 25, 2020, and is subject to change. Readers should recognize the rapidly evolving nature of the COVID-19 outbreak and should personally inform themselves regarding their own state and hospital guidance. Each state and hospital system is likely to have its own unique needs.
Footnotes
Investigation performed at The Ohio State University, Columbus, Ohio
Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/F841).
References
- 1.American College of Surgeons. COVID-19: recommendations for management of elective surgical procedures. 2020. March 13 Accessed 2020 Mar 25. https://www.facs.org/covid-19/clinical-guidance/elective-surgery [Google Scholar]
- 2.Centers for Medicare and Medicaid Services. CMS adult elective surgery and procedures recommendations: limit all non-essential planned surgeries and procedures, including dental, until further notice. Accessed 2020 Mar 25 https://www.cms.gov/files/document/31820-cms-adult-elective-surgery-and-procedures-recommendations.pdf
- 3.Blue Cross Blue Shield Association. Planned knee and hip replacement surgeries are on the rise in the U.S. 2019 Jan 23. Accessed 2020 Mar 25. https://www.bcbs.com/the-health-of-america/reports/planned-knee-and-hip-replacement-surgeries-are-the-rise-the-us [Google Scholar]
- 4.O’Donnell J. Elective surgeries continue at some US hospitals during coronavirus outbreak despite supply and safety worries. 2020. Mar 21, https://www.usatoday.com/story/news/health/2020/03/21/hospitals-doing-elective-surgery-despite-covid-19-risk-short-supplies/2881141001/ Accessed 2020 Mar 25. [Google Scholar]
- 5.Harris S, Office of the Governor of Alabama. Order of the state health officer suspending certain public gatherings due to risk of infection by COVID-19 (applicable statewide). 2020. March 27 Accessed 2020 Mar 25 https://governor.alabama.gov/assets/2020/03/Amended-Statewide-Social-Distancing-SHO-Order-3.27.2020-FINAL.pdf [Google Scholar]
- 6.Dunleavy M, Crum A, Zink A, State of Alaska Office of the Governor. COVID-19 health mandates. Accessed 2020 Mar 25 https://gov.alaska.gov/home/covid19-healthmandates/
- 7.Dulcey DA, State of Arizona Office of the Governor. Executive Order 2020-10. Delaying elective surgeries to conserve personal protective equipment to test and treat patients with COVID-19. 2020. March 19 Accessed 2020 Mar 25 https://azgovernor.gov/sites/default/files/eo_2020-10.pdf [Google Scholar]
- 8.Polis J, State of Colorado. Executive Order D 2020-009. Ordering the temporary cessation of all elective and non-essential surgeries and procedures and preserving personal protective equipment and ventilators in Colorado due to the presence of COVID-19. 2020. March 19 Accessed 2020 Mar 25 https://www.colorado.gov/governor/2020-executive-orders [Google Scholar]
- 9.Broce C, Hall C, State of Georgia Office of the Governor. Gov. Kemp issues new executive orders, provides COVID-19 update. 2020. March 23 Accessed 2020 Mar 25 https://gov.georgia.gov/press-releases/2020-03-23/gov-kemp-issues-new-executive-orders-provides-covid-19-update [Google Scholar]
- 10.Desantis R, State of Florida Office of the Governor. Executive Order Number 20-72. Emergency management—COVID-19—non-essential elective medical procedures. 2020. March 20 Accessed 2020 Mar 25 https://www.flgov.com/wp-content/uploads/orders/2020/EO_20-72.pdf [Google Scholar]
- 11.Illinois Department of Public Health. COVID-19 - elective surgical procedure guidance. Accessed 2020 Mar 25 http://www.dph.illinois.gov/topics-services/diseases-and-conditions/diseases-a-z-list/coronavirus/health-care-providers/elective-procedures-guidance
- 12.Hoffmeyer R, State of Indiana. Gov. Holcomb announces more steps to slow the spread of COVID-19. 2020. March 16 Accessed 2020 Mar 25 https://calendar.in.gov/site/gov/event/gov-holcomb-announces-more-steps-to-slow-the-spread-of-covid-19/ [Google Scholar]
- 13.Commonwealth of Kentucky Cabinet for Health and Family Services Office of Legal Services. March 23 2020. Accessed 2020 Mar 25 https://governor.ky.gov/attachments/20200323_Directive_Elective-Procedures.pdf
- 14.Louisiana. Healthcare Facility Notice #2020-COVID19-ALL-06. Mar 18, 2020. http://ldh.la.gov/assets/oph/Coronavirus/resources/providers/LDH-Notice-Medical-Surgical-Procedures.pdf Accessed 2020 Mar 25. [Google Scholar]
- 15.State of Maine Office of Governor Janet T. Mills. Governor announces significant recommendations & signs civil emergency proclamation to respond to COVID-19 in Maine. 2020. March 15 Accessed 2020 Mar 25 https://www.maine.gov/governor/mills/news/governor-announces-significant-recommendations-signs-civil-emergency-proclamation-respond. [Google Scholar]
- 16.Neal RR, Maryland Department of Health. Directive and order regarding various healthcare matters. 2020. March 23 Accessed 2020 Mar 25 https://governor.maryland.gov/wp-content/uploads/2020/03/03.23.2020-Sec-Neall-Healthcare-Matters-Order.pdf. [Google Scholar]
- 17.Kelley E, Commonwealth of Massachusetts Bureau of Health Care Safety and Quality. Nonessential, elective invasive procedures in hospitals and ambulatory surgical centers during the COVID-19 outbreak. 2020. March 15 Accessed 2020 Mar 25 http://www.massmed.org/Patient-Care/COVID-19/Nonessential,-Elective-Invasive-Procedures-in-Hospitals-and-Ambulatory-Surgical-Centers-during-the-COVID-19-Outbreak---MEMO/ [Google Scholar]
- 18.State of Michigan Office of Governor Gretchen Whitmer. Temporary restrictions on non-essential medical and dental procedures. 2020. March 21 Accessed 2020 Mar 25 https://www.michigan.gov/whitmer/0,9309,7-387-90499_90705-522451--,00.html
- 19.Walz T, State of Minnesota. Emergency Executive Order 20-09. Directing delay of inpatient and outpatient elective surgery and procedural cases during COVID-19 peacetime emergency. 2020. March 19 Accessed 2020 Mar 25 https://www.leg.state.mn.us/archive/execorders/20-09.pdf [Google Scholar]
- 20.Mississippi State Department of Health. COVID-19: elective surgical procedures must be rescheduled. 2020. March 19 Accessed 2020 Mar 25 https://msdh.ms.gov/msdhsite/_static/23,21854,341.html [Google Scholar]
- 21.Nebraska. Coronavirus COVID-19 information. 2020. March 18 Accessed 2020 Mar 25 https://www.douglascounty-ne.gov/coronavirus-covid-19-information [Google Scholar]
- 22.Murphy PD, State of New Jersey. Executive Order No. 109. 2020. March 23 Accessed 2020 Mar 25 https://nj.gov/infobank/eo/056murphy/pdf/EO-109.pdf [Google Scholar]
- 23.Cuomo AM, New York State. Executive Order No. 202.10. Continuing temporary suspension and modification of laws relating to the disaster emergency. 2020. March 23 Accessed 2020 Mar 25 https://www.governor.ny.gov/news/no-20210-continuing-temporary-suspension-and-modification-laws-relating-disaster-emergency [Google Scholar]
- 24.North Carolina Department of Health and Human Services. 2020. March 20 https://files.nc.gov/ncdhhs/COVID-19-Elective-Surgeries.pdf
- 25.Acton A, Ohio Department of Health. Re: director’s order for the management of non-essential surgeries and procedures throughout Ohio. 2020. March 17 Accessed 2020 Mar 25 https://coronavirus.ohio.gov/wps/wcm/connect/gov/e7cee147-0f86-438b-ae1f-c5922f46c47c/Director%27s+Order+non-essential+surgery+3-17-2020.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=ROOTWORKSPACE.Z18_M1HGGIK0N0JO00QO9DDDDM3000-e7cee147-0f86-438b-ae1f-c5922f46c47c-n3GxdDg [Google Scholar]
- 26.Brown K, State of Oregon Office of the Governor. Conserving personal protective equipment and hospital beds, protecting health care workers, postponing non-urgent health care procedures, and restricting visitation in response to coronavirus (COVID-19) outbreaks. 2020. March 19 Accessed 2020 Mar 25 https://www.oregon.gov/gov/admin/Pages/eo_20-10.aspx [Google Scholar]
- 27.Pennsylvania Department of Health. Guidance on ambulatory surgical facilities’ responses to COVID-19. 2020. March 20 Accessed 2020 Mar 25 https://www.health.pa.gov/topics/Documents/Diseases%20and%20Conditions/Guidance%20on%20Ambulatory%20Surgical%20Facilities%E2%80%99%20Responses%20to%20COVID-19.pdf [Google Scholar]
- 28.Noem K, State of South Dakota Office of the Governor. Executive Order 2020-08. 2020. March 23 Accessed 2020 Mar 25 https://sdsos.gov/general-information/executive-actions/executive-orders/assets/2020-08.PDF [Google Scholar]
- 29.Lee B, State of Tennessee. Executive Order No. 18. An order to reduce the spread of COVID-19 by limiting non- emergency healthcare procedures. 2020. March 23 Accessed 2020 Mar 25 https://publications.tnsosfiles.com/pub/execorders/exec-orders-lee18.pdf [Google Scholar]
- 30.Abbott G, State of Texas. Executive Order GA-09. 2020. March 22 Accessed 2020 Mar 25 https://lrl.texas.gov/scanned/govdocs/Greg%20Abbott/2020/GA-09.pdf [Google Scholar]
- 31.Herbert GR, State of Utah. State public health order. 2020. March 23 Accessed 2020 Mar 25 https://coronavirus.utah.gov/state-restricts-non-elective-surgeries/ [Google Scholar]
- 32.Scott PB, State of Vermont. Addendum 3 to Executive Order 01-20. Suspension of all non-essential adult elective surgery and medical and surgical procedures. 2020. March 20 Accessed 2020 Mar 25 https://governor.vermont.gov/sites/scott/files/documents/ADDENDUM%203%20TO%20EXECUTIVE%20ORDER%2001-20.pdf [Google Scholar]
- 33.Virginia. Coronavirus disease 2019 (COVID-19): frequently asked questions. 2020. March 19 Accessed 2020 Mar 25 http://www.vdh.virginia.gov/content/uploads/sites/182/2020/03/General-Questions-FAQ_03.19.20_FINAL.pdf
- 34.Inslee J, State of Washington Office of the Governor. Proclamation by the governor amending Proclamation 20-05. 20-24 restrictions on non urgent medical procedures. 2020. March 19 Accessed 2020 Mar 25 https://www.governor.wa.gov/node/495945 [Google Scholar]
- 35.Ohio Hospital Association. Implementing guidelines for the management of non-essential surgeries and procedures throughout Ohio. 2020. March 16 Accessed 2020 Mar 16 https://ohiohospitals.org/OHA/media/OHA-Media/Documents/Patient%20Safety%20and%20Quality/COVID19/Elective-Surgery-Guidance-March-2020.pdf?_cldee=dGltLmNhaGlsbEBkaW5zbW9yZS5jb20%3D&recipientid=contact-4d2cb8823105e71180dc005056b90754-e93bf0bdad99411bbb4c2bc5505e711e&esid=9027d884-8d68-ea11-a2db-005056a0e71c [Google Scholar]
- 36.Fischer SJ. What to do if your orthopaedic surgery is postponed. Accessed 2020 Mar 27 https://www.orthoinfo.org/en/treatment/what-to-do-if-your-orthopaedic-surgery-is-postponed/