In the past month, Tampa’s BayCare Health System has seen a tenfold increase in Covid-19 patients at its 14 acute care hospitals in central Florida. Expecting this surge to get worse, its executives decided to pause elective surgeries starting Saturday to avoid staffing shortages.
“The last thing we want to do is get into a bind where we’ve got more demand than we have resources and run the risk of patients being jeopardized,” said Glenn Waters, executive vice president of BayCare.
In Texas, Gov. Greg Abbott wrote a letter to the Texas Hospital Association earlier this week urging hospitals to consider pausing elective surgeries as the more transmissible Delta variant fuels mounting Covid hospitalizations there as well. Many hospitals such as Ben Taub Hospital in Houston were already pausing procedures because of concerns with resources, and others are now evaluating surgeries on a case-by-case basis to determine if they can be postponed.
As during the pandemic’s first wave a year ago, hospitals in hard-hit places, including Florida, Louisiana, and Tennessee, have in recent days had to pause, delay, or reschedule tests, procedures, and surgeries that are considered “elective” and nonurgent. This means that hospital staff are going through a frustrating moment of déjà vu.
“It’s just agonizing to have to go through this with our patients again,” said Avital O’Glasser, medical director of the preoperative medicine clinic at Oregon Health and Science University Hospital. Even though her hospital has not canceled surgeries yet, “it’s mentally and emotionally tough to be staring down this possibility again.”
It’s all the more worrying because the pandemic has proven that although some procedures may not be considered urgent, patients suffer nonetheless when they’re delayed. Many doctors saw how, when patients were eventually allowed to get their procedures done last year, they arrived in worse conditions. Now, with that knowledge, some physicians and administrators are trying to be more selective in what procedures they postpone this time.
Though calling a surgery “elective” may suggest that it is a choice, in general, elective procedures are those that can be scheduled in advance, and delaying them is not life-threatening. It is a procedure that does not need to be done at the moment “to maintain life or limb,” explained Brian Cole, chair of surgery at Rush Oak Park Hospital in Chicago. “But it’s a very nebulous term to call something elective.”
Last year, this designation included almost all operations, including heart and cancer surgeries. Experts agree this initially made sense in the face of personal protective equipment shortages and limited hospital beds. Now that hospitals are better prepared and no longer facing these shortages, many are being more selective about what gets canceled. Instead of a general pause, most hospitals are examining case by case to determine whether and how long a particular procedure can be delayed. For example, Vanderbilt University Medical Center examines cases each morning to decide what can be rescheduled based on the particularities of a case.
The shift happened because delaying certain procedures may have detrimental consequences. One such surgery is a heart procedure called transcatheter aortic valve replacement. One study from Mount Sinai Hospital in New York found that deferring this treatment led to 10% of patients experiencing a cardiac event during the first month, and 35% experienced one in the next three months.
“Nothing would have happened [to the patients] if the procedures were not placed on hold,” said Stamatios Lerakis, director of noninvasive cardiology at Mount Sinai and author of the study. He suggests that patients can be stratified depending on how vulnerable they would be to a delay in their procedure. In the study, patients who had a previous cardiac event fared worse.
A similar study from the University of Bern in Switzerland found that deferring aortic valve replacement increased the risk of hospitalization and worsening heart failure. According to a report from the British Heart Foundation, there were 5,800 excess deaths from heart and circulatory conditions in 2020 in the U.K., and it concluded that Covid-driven delays in cardiology care, such as echocardiograms, procedures to fit and implant pacemakers, and heart valve surgeries, potentially contributed to this number.
Patients needing other types of surgeries are also worse off now than before the pandemic. For example, surgeons at Covenant High Plains Surgery Center in Lubbock, Texas, saw an uptick in higher acuity cases — there was about a 10% increase in the severity of patients that were coming into the center. “Patients who had delayed their procedures may have had more complex procedures or may have come in sicker as a result,” said Alfonso del Granado, administrator and CEO of the center.
O’Glasser, who prepares patients for their surgeries at OHSU Hospital, is seeing the same trend. “On average, patients are more medically complex than they were before the pandemic,” she said.
Deferring a procedure, for more than a few weeks, could allow conditions or diseases to progress unchecked, said Seth Karp, surgeon-in-chief at Vanderbilt University Medical Center in Nashville, Tenn. For example, routine screenings, such as colonoscopies and mammograms, declined in the United States, which could lead to a missed chance to catch and treat cancer in a timely manner.
Even delaying surgeries that may seem less urgent, like orthopedic surgeries, could impact a patient’s daily life. Two surveys done by the American Association of Hip and Knee Surgeons Research Committee in April and December of 2020 of about 1,000 orthopedic patients that had to delay their surgeries found that patients experienced increased anxiety and continued pain, impacting their daily functioning. Particularly for elderly patients, if hospitals delay orthopedic surgeries, like hip replacements, the risk of blood clotting, pulmonary embolism, and morbidity goes up.
Seth Trueger, an emergency physician at Northwestern Medicine in Chicago, points out that it’s additive: If a patient doesn’t get a knee surgery, for example, it could lead to chronic pain, which would deter them from exercising and may bring on other conditions, ultimately leading to decreased quality of life and life expectancy.
“There are clearly conditions that, if neglected and go without surgery, will end up in a different place later on if that surgery does not occur,” said Cole. But more studies will be needed to quantify and reveal the scope of the yet unseen impact of surgery delays on patients.
Hospitals that are part of larger systems could potentially transfer their patients to other hospitals in their network to get the necessary procedures. But in places like Florida and Texas, where Covid-19 cases are increasing all around, this strategy doesn’t work. Specialty surgical centers such as standalone surgery centers like the one in Lubbocks could provide a release valve for strained hospitals in some places since they do not attend to Covid-19 patients.
But the most effective solution? Every expert STAT asked had the same answer: vaccinations and masking. They say that the way out of an elective surgery pause is by addressing the problem at the root: Only by decreasing the number of Covid-19 cases hospitals have to attend to could they start elective surgeries back again and get back to providing better care to all patients beyond those with Covid-19.