Doctors want to handle another delay in elective surgeries differently

In last month, Tampa BayCare Health System increased tenfold in Covid-19 patients at its 14 acute care hospitals in central Florida. Expecting this increase to worsen, its executives decided pause elective surgeries starting Saturday to avoid staff shortages.

“The last thing we want to do is get into a mess where we have more demand than resources and we risk compromising patients,” said Glenn Waters, executive vice president of BayCare.

In Texas, Governor 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 increases Covid hospitalizations there as well. Many hospitals, such as Ben Taub Hospital in Houston, were already pausing procedures due to resource concerns, and other now they are evaluating surgeries on a case-by-case basis to determine if they can be postponed.

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As during the first wave of the pandemic a year ago, hospitals in the hardest 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 not urgent. This means that the hospital staff is going through a frustrating time of déjà vu.

“It’s nerve-racking 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. Although his hospital has yet to cancel the surgeries, “it is mentally and emotionally difficult to contemplate this possibility again.”

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It’s even more concerning because the pandemic has shown that while some procedures may not be considered urgent, patients suffer when they are delayed. Many doctors saw how, when patients were finally allowed to have their procedures last year, they arrived in worse condition. Now, with that knowledge, some doctors and administrators are trying to be more selective in the procedures they postpone this time.

Although calling surgery “elective” may suggest that it is an option, in general, elective procedures are those that can be scheduled in advance and are not life-threatening to delay. It’s a procedure that doesn’t need to be done at this time “to maintain life or a limb,” explained Brian Cole, president 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 that this initially made sense given the shortage of personal protective equipment 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. Rather than a general pause, most hospitals look at it on a case-by-case basis to determine if and for how long a particular procedure can be delayed. For example, Vanderbilt University Medical Center reviews cases every morning to decide what can be rescheduled based on the specifics of a case.

The change happened because delaying certain procedures can have detrimental consequences. One of those surgeries is a heart procedure called transcatheter aortic valve replacement. A study from Mount Sinai Hospital in New York found that postponing this treatment led to 10% of patients experiencing a cardiac event in the first month, and 35% experiencing one in the next three months.

“Nothing would have happened [to the patients] if the procedures weren’t put on hold, ”said Stamatios Lerakis, director of non-invasive cardiology at Mount Sinai and author of the study. He suggests that patients can be stratified depending on how vulnerable they are to a delay in their procedure. In the study, patients who had a prior cardiac event fared worse.

TO similar study from the University of Bern in Switzerland found that delaying aortic valve replacement increased the risk of hospitalization and made heart failure worse. According to a report by the British Heart Foundation, there were 5,800 excess deaths of heart and circulatory disease in 2020 in the UK, and 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 who need other types of surgeries are also worse off now than before the pandemic. For example, surgeons at the Covenant High Plains Surgery Center in Lubbock, Texas, saw an increase in cases of higher acuity – there was an approximately 10% increase in severity for patients entering the center. “Patients who had their procedures delayed may have had more complex procedures or may have become more ill as a result,” said Alfonso del Granado, administrator and executive director 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,” he said.

Putting off a procedure, for more than a few weeks, could allow conditions or diseases to progress uncontrollably, said Seth Karp, chief surgeon at Vanderbilt University Medical Center in Nashville, Tennessee. For example, routine exams, such as colonoscopies and mammograms, rejected in the United States, which could lead to missing the opportunity to get and treat cancer in a timely manner.

Even delaying surgeries that may seem less urgent, such as orthopedic surgeries, could affect a patient’s daily life. Two surveys conducted by the Research Committee of the American Association of Hip and Knee Surgeons in April Y December 2020 of approximately 1,000 orthopedic patients who had to delay their surgeries found that patients experienced increased anxiety and ongoing pain, affecting their daily functioning. Particularly for elderly patients, if hospitals delay orthopedic surgeries, such as hip replacements, the risk of blood clotting, pulmonary embolism and morbidity increases.

Seth Trueger, an emergency room physician at Northwestern Medicine in Chicago, notes that it is additive: If a patient does not have knee surgery, for example, it could lead to chronic pain, which would discourage him from exercising, and could lead to other conditions, which ultimately lead to a decrease in quality of life and life expectancy.

“Clearly there are conditions that, if neglected and not operated on, will end up in a different place later if that surgery doesn’t happen,” Cole said. But more studies will be needed to quantify and reveal the extent of the unseen impact of surgery delays on patients.

Hospitals that are part of larger systems may transfer their patients to other hospitals in their network to obtain necessary procedures. But in places like Florida and Texas, where Covid-19 cases are on the rise everywhere, this strategy doesn’t work. Specialized surgical centers, such as freestanding surgery centers like the one in Lubbocks, could provide a release valve for hospitals with problems in some locations, as they do not see Covid-19 patients.

But the most effective solution? All the experts STAT asked had the same answer: vaccines and masking. They say the way to get out of an elective surgery break is to tackle the problem from the root: only by decreasing the number of Covid-19 cases that hospitals must treat could elective surgeries start again and bring better care to everyone again. patients beyond those with Covid-19.

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