Hospitals must stop elective surgeries to flatten the curve

Health systems across the United States are responding unevenly to the COVID-19 pandemic, and the lack of coordination is placing health care workers and patients alike at undue risk. Many hospitals have continued with business as usual for much of the past week, despite the recommendation to suspend elective surgeries echoed by the U.S. Surgeon General, the American College of Surgeons and the Centers for Disease Control and Prevention. The American Cancer Society has also urged that patients forego routine procedures and cancer screenings like colonoscopies. At a White House briefing from the Coronavirus Task Force on Wednesday, Vice President Pence, too, advised limitations on all non-essential medical and surgical procedures, and Administrator Seema Verma of the Centers for Medicare and Medicaid Services announced that guidelines would be forthcoming.

Yet in some hospital systems, including one I know in Northern Virginia, cosmetic and other non-essential surgeries continued the day after the White House announcement, even as a shortage of masks was becoming evident. Carrying on with elective surgeries and routine procedures in the current climate threatens to deplete human resources by exposing workers to possible infection, and depleting limited equipment supplies — including masks, personal protective equipment and, more ominously, blood supplies and respirators — for when they are most needed in the coming weeks as the virus spreads.

As many industries have shuttered, it has become verboten to go to the mall or out for a beer, or even to work — yet some citizens have still been showing up at surgery centers and hospitals for cosmetic and other non-emergency surgeries and procedures. Major retailers, including Apple, Ikea and H&M, have voluntarily closed their doors to help curb spread of the virus. More than half a dozen states, including California, Illinois, and Massachusetts, have imposed restrictions on restaurant and bar service, causing many establishments to close or limit service for fear of hastening community transmission. So, it makes no sense that where infection is most likely to be transmitted — in hospitals and other medical facilities — reasonably healthy patients have continued to be welcomed for elective procedures that expose them and clinicians to the risk of infection, while using critical resources for currently superfluous purposes.

Stanford Anesthesiologist Dr. Alyssa Burgart, noting that 41 percent of cases of COVID-19 in Wuhan were likely hospital acquired, points to the primary reason that the system seems slow to cancel elective cases — namely that elective surgeries and colonoscopies account for almost $500 billion in revenue for the over 50 million procedures performed annually. The health sector, as every other, is likely to suffer substantial financial loss due to the pandemic. And, just like retailers and restaurateurs, the health sector must absorb its share of these costs by limiting its normal operations to help mitigate morbidity and mortality as the crisis unfolds.

Public health initiatives can contribute to slowing the spread of the virus so that outcomes in the U.S. do not reach the dire proportions observed in Italy and elsewhere, though it already seems that the number of U.S. cases is likely to double every four to seven days. Various jurisdictions and health systems have responded with limiting measures. Most hospitals, medical and dental offices in and around Baltimore, for instance, agreed last week to cancel or postpone any case that is not urgent. Kaiser Permanente’s VP called the move an attempt to head off the expected exhaustion of “supplies, equipment, and our people” as COVID-19 advances. Hospitals in Oregon and some of Washington followed suit, though some hard hit Seattle hospitals had already stopped elective surgeries prior to the Surgeon General’s recommendation on March 14, as did hospitals in the San Francisco Bay area, in anticipation of an “accelerated spread of cases.” The Governor of Maine signed a civil emergency proclamation on March 15th “postponing all non-urgent medical procedures.” And In Canada, Ontario’s Health Minister, Christine Elliott, called that same day for the careful ramping down of elective surgeries to preserve capacity for pandemic response.

Health care workers will be called upon to be the heroes working the front lines of the COVID-19 pandemic as it crests in the U.S. In doing so they should not be subjected to undue risk. Given that transmission has been shown to be possible from asymptomatic sources and that testing has been sparse and insufficient in the U.S., the true prevalence of COVID-19 is unknown, and any medical procedure may expose patients and clinicians to the risk of contracting, and spreading, the virus. Further, allowing elective surgeries to continue may squander resources sorely needed as transmission unfolds.

Mishandled messaging about the seriousness of the COVID-19 crisis came from the top, where President Trump long denied that it was any worse than the flu and asserted that it was under control. And, while recommendations to restrict elective surgeries were made from credible sources like Surgeon General Jerome Adams and Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, their admonitions had no real teeth and were open to interpretation, with health systems and clinicians free to proceed as they pleased. Indeed, the hospital lobby, including the American Hospital Association, pushed back on these public health recommendations, arguing that “any curtailment must be nuanced,” ostensibly in the interest of patients, but more likely with an eye on the bottom line.

The consensus of public health professionals has been emphatically in favor of definitive measures to “flatten the curve” — slowing transmission to avoid overwhelming limited health system capacity and attendant unnecessary deaths.

Many believe such measures have already come too late and too inconsistently.

Now more drastic means may be needed to forestall a trajectory akin to Italy’s, where some 3,000 people have died — almost 500 in just one day last week — and there is a shortage of needed respirators. Shutting down elective surgeries and ensuring that health care workers have sufficient personal protective equipment are two measures that must be broadly adopted.

The Trump administration — and health system administrators — must be held accountable for ensuring that new guidelines to restrict non-essential surgeries are adhered to, so that they actually achieve their goals of preserving equipment and clinician capacity to deal with the pandemic, while protecting patients from unnecessary exposure to the virus.

Bonnie Stabile is the director of the Master of Public Policy Program and of the Gender and Policy Initiative at George Mason University’s Schar School of Policy and Government. Follow her on Twitter @bstabile1