Hospitals have made drastic changes to prevent coronavirus exposure among patients and health-care providers. Many are running on skeleton crews to avoid mass quarantine or infection of doctors, which would destabilize the entire health-care system. Clinics have been shut down, in-person meetings canceled and visitors restricted. But patients need to be prepared for the next wave of change, including the cancellation of scheduled surgeries and procedures, which will allow hospitals to concentrate resources where they’re needed: on critically ill covid-19 patients.
Massachusetts General Hospital announced hospital-wide cancellations of all elective surgeries starting Monday until further notice. New York Presbyterian and Northwell Health in New York followed suit, suspending all non-urgent surgeries starting this week. It’s a matter of time before surgery cancellations become commonplace across most U.S. hospitals. The American College of Surgeons and the U.S. surgeon general recommend that consideration be given to canceling elective surgeries countrywide.
This extreme measure is “essential for many reasons,” says Keith Lillemoe, chief of the department of surgery at Massachusetts General Hospital. It keeps patients and families at home, limiting their exposure to potentially infected people. It protects health-care workers, who must remain healthy to ensure that hospitals continue to function.
It’s also about conservation of resources. Surgeries are resource-intensive — requiring surgeons, anesthesiologists, nurses, transport teams, medical beds and equipment such as ventilators. Suspending elective surgeries will free up those doctors, other medical personnel, and rooms and equipment.
At my hospital, surgery cancellations already are allowing us to prioritize covid-19 patients rather than dedicating time to non-urgent surgeries. Because of the number of health-care workers required to work close to one another for each surgery, I have no doubt that continuing to perform non-urgent surgeries would lead to further spread of the virus among health-care workers.
Hospitals will, of course, still perform urgent and emergency surgeries. Certain cancer and heart surgeries will go ahead as well. Some hospitals, like mine, are trying to accommodate small elective cases at sites away from the main hospital.
Who decides whether your surgery will be canceled? The surgeon, says Lillemoe. Hospital administrators are not deciding; medical experts are. From my experience and conversations with several other surgeons, this is consistent across the board at most hospitals. Each elective surgery is decided on a case-by-case basis.
To aid in deciding urgent vs. non-urgent, hospitals should be developing a triage algorithm, says David Hoyt, executive director of the American College of Surgeons, whose organization plans to release a triage primer as a guide for hospitals. Algorithms can help hospitals assign patients into tiers based on low, intermediate and high acuity. An orthopedic surgery in a patient who has minimal symptoms probably can be delayed. A surgery for a low-risk cancer also could be delayed. But certain cancers have a time window and surgeries probably should not be postponed, Hoyt says. Each hospital has different resource capacities that also must be considered.
Despite the sound logic and understanding, coping with planned surgery cancellations isn’t easy for patients, many of whom have waited months for a surgery date.
Nicole Gibbs, a Bay Area resident, is due to have surgery in April for a thyroid mass that has a 75 percent chance of being cancer, according to her doctors. The possibility of a canceled surgery has her worried. “My doctors told me I could wait three to six months from diagnosis to surgery, and it’s already been three months,” she told me. “I tried very hard to get every appointment as early as possible to make this surgery date a possibility. If it’s canceled, I don’t know when it would be delayed until. And I’m worried the more I delay, the higher the chance of spread.” She agrees with the need to conserve hospital resources for coronavirus patients, but her case also underscores how hard these decisions are for providers.
Others with less-pressing surgeries are taking proactive steps to help hospitals cope. Sarafina Nance, a graduate student at the University of California at Berkley, had a preventive double mastectomy and reconstruction in November for an elevated risk of breast cancer. Nance scheduled a second, related surgery this month to avoid another large deductible after the insurance cycle renews. “I actually decided to hold off on the surgery myself,” she said. “My surgeon agreed. I am trying to be proactive and flatten the curve as much as I can. I don’t want to take up a hospital bed. And I don’t want to undergo surgery at a time when I could be putting myself at risk for coronavirus during the recovering process.”
The bottom line for patients is: Though your elective surgery is likely to be canceled in the coming weeks, your doctors are here to help. If you have concerns about delaying treatment, make sure you have an honest conversation with your surgeon. If you think your surgery is completely elective and you don’t mind postponing, discuss this as well. It is unclear when elective surgeries will be rescheduled, and there will be a backlog of cases. Hospitals are going to get hit harder as the coronavirus spreads. Right now, hospitals are running smoothly, and patient care has not been compromised. Communication is key, and we are all in this together.
An earlier version of this story gave the wrong title for David Hoyt of the American College of Surgeons. He is the executive director, not the president.