Governor Andrew M. Cuomo announced today that elective outpatient treatments can resume in counties and hospitals without significant risk of COVID-19 surge in the near term. Restrictions on elective surgery will remain in place in Bronx, Queens, Rockland, Nassau, Clinton, Yates, Westchester, Albany, Richmond, Schuyler, Kings, Suffolk, New York, Dutchess, Sullivan, Ulster, Erie, Orange and Rensselaer Counties as the state continues to monitor the rate of new COVID-19 infections in the region.
Hospitals will be able to resume performing elective outpatient treatments on April 28, 2020 if the hospital capacity is over 25 percent for the county and if there have been fewer than 10 new hospitalizations of COVID-19 patients in the county over the past 10 days. If a hospital is located in a county eligible to resume elective outpatient treatments, but that hospital has a capacity under 25 percent or has had more than 10 new hospitalizations in the past 10 days, that hospital is not eligible to resume elective surgeries.
If a county or hospital that has resumed elective surgery experiences a decrease in hospital capacity below the 25 percent threshold or an increase of 10 or more new hospitalizations of COVID-19 patients, elective surgeries must cease.
Further, patients must test negative for COVID-19 prior to any elective outpatient treatment. The State Department of Health will issue guidance on resuming elective surgeries.
AAOS Guidance
The Academy believes that decisions regarding when and how elective surgery should begin are best decided on a local basis. To help members prepare for these conversations, they have developed clinical considerations for navigating COVID-19 and are recommending the following universally applied guiding principles:
- All decisions should be locally based as resource availability is locally determined. These resources include:
a. Hospital beds,
b. ICU beds,
c. Ventilators,
d. PPE, and
e. Healthcare workers.
- Overall disease burden varies by location: Hot spots like New York City and New Orleans have high case rates.
- Stage of pandemic varies by location. (Reproductive number*: greater, equal or less than one. Is the curve increasing, flattening or decreasing?)
- Legal restrictions vary by location: We need to adhere to government mandates; however, these vary by state. (For example, New York State is in place until 4/30/2020, while Oklahoma is in place until 4/24/2020.)
* Reproductive Number: It is the average number of secondary infections produced by a typical case of an infection in a population where everyone is susceptible. If the number is >1, then the case numbers increase. If it is <1, they decrease.
Once the decision is made to resume elective surgery, other important issues that must be addressed include:
- Velocity of return,
- Location of return,
- Prioritization of surgical cases, and
- COVID-19 testing (for both patients and staff).
Again, decisions regarding these factors are best made on a local basis. For example, in areas of low disease burden, elective surgery may not need to be phased in and can start all at once. In other areas, where personnel and equipment have been repurposed, a more phased-in approach is necessary. The principles guiding velocity of return include:
- Resource availability (repurposed staff and equipment)
- Utilization of “COVID-19 free” hospitals or ASCs when possible
- Ambulatory cases first (to avoid hospitalization and COVID-19 exposure)
- Inpatient cases (ASA I and II)
- Inpatient cases (ASA III and IV), once COVID exposure as inpatient is minimized and COVID-19 testing is perfected
There is much debate about the availability and utility of COVID-19 testing for patients and staff. Despite the debate, it is likely that perioperative patient testing and universal staff testing will be required.
CMS Recommendations
The new CMS recommendations for reopening facilities can be found here
White House
The Guidelines for Opening Up America Again can be found here
