April 20, 2020
The U.S. remains in the midst of the COVID-19 pandemic. Our country now leads the world in both number of cases and number of fatalities. However, there is some heartening data: The two major hot spots in the U.S.—New Orleans and New York City—have seen a decrease in the number of new cases and, over the last week, hospital admissions have lagged behind discharges. Other parts of the country are still on the upward portion of the curve but it appears that, in many places, the slope of the curve is not as steep as once predicted and healthcare resources may be ample to handle the COVID-19 burden. These factors have fueled the discussion of when and how we will be able to resume “normal” activity, i.e., elective surgery.
Your 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, we 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,
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.
The most widely used and widely available test is the Reverse Transcriptase PCR (RT-PCR) antigen test. This test detects SARS CoV-2 viral RNA (ANTIGEN) in oropharynx and nasal pharynx. It is highly sensitive, since it detects both viable and nonviable viral RNA. Patients may remain positive for up to one month after onset of disease. False positives are an issue, since nonviable viral RNA fragments can trigger a positive test, but they are not clinically significant. Additionally, improper sampling technique (inaccurate swabbing) can lead to false negative results. Positives of the RT-PCR test include that it is readily available and can be resulted in 2 to 3 hours.
Much has been written about the antibody test. This is an ELISA test that measures the antibodies against the viral spike protein. At 14 days after onset of symptoms, nearly 100% of patients will have antibodies. The antibodies are thought to provide immunity and prevent spread to others. It is still not known how long immunity lasts. The FDA has relaxed its normally rigorous approval process, leading to an increasing number of tests becoming available. However, the accuracy of some of these tests is unproven. At some point, the serum ELISA antibody test will be the gold standard, but we are probably not there yet.
I would be remiss if I did not include an update on the Federal Government’s relief and stimulus programs. There will be an addition to the CARES Act (Phase 3). The $350 billion in funds designated for both the Paycheck Protection Program and the Economic Injury Disaster Loan Program in CARES was depleted on April 16th. While there is broad bipartisan agreement that the funding be replenished in a “Phase 3.5” bill, it is being held up because there is conflict on whether that money should go out attached to other funds. Any deal must be able to pass unanimously since Congress is currently not set to return until May 4th, although that date could be extended again. A unanimous deal will allow Congress to plus up this funding without having to be physically present.
The Phase 4 package is still currently being considered by Congress. There are certain provisions that we know are being considered for healthcare. These include increased liability protections during the pandemic, increased funding for the Federal Medicaid Assistance Program, delay in Medicaid Fiscal Accountability Regulations, and a potential increase in funds delegated to healthcare providers directly affected by the pandemic. The timing for Phase 4 is unknown.
I apologize for the length of this correspondence, but there is much to share with you. My sanguine tone belies the fact that this pandemic is still with us. We have lost more than 38,000 souls to this disease. Many of you have fallen ill yourselves or have lost friends and loved ones. All of us are doing what we must to help our communities survive these difficult times.
Your Academy, through its advocacy efforts, continues to work to ensure that you get the relief you deserve to maintain practice solvency and retain employees. We remain completely aligned in all our efforts on behalf of our patients and our profession. I am convinced that, together, we will all emerge stronger and better for it.
Stay safe and healthy.
Joseph A. Bosco III, MD, FAAOS