- A month after the Centers for Medicare and Medicaid Services advised hospitals to delay non-essential medical procedures to prioritize coronavirus response, the agency on Sunday issued the first in a series of recommendations on how states or regions with stabilized outbreaks and meeting certain criteria can begin re-instituting elective surgeries.
- The guidelines follow a similar set of principles issued by the American College of Surgeons on Friday, which emphasizes that healthcare systems consider appropriate timing for resuming elective operations and take steps to prepare equipment and facilities, assess workforce staffing, and prioritize cases.
- The forward-looking documents come as President Donald Trump's three-part plan to reopen the country names resuming outpatient elective surgeries as a Phase One priority, and resuming inpatient elective procedures as a Phase Two item. More locally, some states — including Texas, Alaska and Oklahoma — have taken steps in recent days to loosen restrictions on performing elective procedures.
CMS, the American College of Surgeons and the Surgeon General first advised hospitals to postpone elective procedures in mid-March, an effort to preserve personal protective equipment and staff for coronavirus cases, and to minimize non-coronavirus patients' exposure to the infection.
What followed was a wave of cancelations to procedures across the country. Medical device manufacturers including Johnson & Johnson, Abbott and Intuitive Surgical, in reporting earnings results last week, said the phenomenon noticeably dented sales at the end of the first quarter. Hospitals have also taken financial hits in losing revenue from the more lucrative procedures.
Now, CMS and ACS are rolling out recommendations on how hospitals in certain parts of the U.S. can begin considering how to safely restore elective procedure caseloads.
The CMS guidance on restarting non-COVID-19 care hinges on hospitals meeting "gating criteria" laid out in the Trump reopening plan, which say a state or region should have downward trajectories of flu and COVID-19-like symptoms within a 14-day period; of documented cases or positive tests as a percent of total tests when testing volumes are flat or increasing; and hospitals are treating all patients without crisis care and have robust testing in place for at-risk healthcare workers, including emerging antibody testing.
The American Hospital Association said it "welcomes and supports" the CMS guidance, especially the deference it pays to hospitals and local officials.
"This CMS guidance is clearly focused on addressing important health care needs for non-COVID patients, with decisions being made by providers in collaboration with local and state public health leaders," AHA said in a statement.
With COVID-19 rates expected to peak at different times in local communities over the coming weeks, the ACS guidance echoes the White House in calling for a phased approach to resuming the full scope of activities that make up everyday life, in schools, the workplace, parks and other public places.
ACS is emphasizing the importance of understanding where local healthcare facilities fall in this spectrum, taking into account factors such as workforce and supply chain constraints and bed, testing and operating room capacity. The document, called "Local Resumption of Elective Surgery Guidance," advises reintroducing elective surgeries once COVID-19 has peaked in a given area while acknowledging the potential for subsequent waves of infections.
"It has been recommended that a decrease in measures of COVID-19 incidence for at least 14 days should be considered before transitioning to provide surgical services for patients without immediately life- or limb-threatening conditions," the document states.
In a section on testing, the surgeons group recommends facilities develop policies for both patients and healthcare workers that take into account availability of diagnostic screening and turnaround times. The reversal of physical distancing policies could lead to an increase in infection incidence, including among healthcare workers, the group cautions.
Facilities are advised to have stored inventory or a reliable supply chain of personal protective equipment optimally for at least 30 days of operations.
ACS also issued a joint statement with the American Hospital Association, American Society of Anesthesiologists, and Association of periOperative Registered Nurses with further suggestions for preparing facilities, noting the potential for large pent-up demand.
The ACS also said it has developed a patient registry available to all hospitals willing to collect and report data about their COVID-19 patients.