CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)

The CDC has released guidance for healthcare systems to “balance the need to provide necessary services while minimizing risk to patients and healthcare personnel (HCP). . . . [And] consider the local level of COVID-19 transmission when making decisions about the provision of medical services,” noting that “considerations may change over time and vary by practice type and setting.”[1]

The CDC categorizes its key considerations into three broad categories for healthcare providers: Be prepared to rapidly detect and respond to an increase of COVID-19 cases in the community; Provide care in the safest way possible; Consider that services may need to expand gradually.[2]

For non-COVID related care, the CDC released a table emphasizing consideration for patient harm against the rate of community transmission, which categorizes health care procedures and needs by how much harm would be done to a patient if the patient was denied the treatment and how expansive transmission of COVID-19 has been in the facility or community.[3]

CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)

On April 7, 2020, CMS released the Non-Emergent, Elective Medical Services, and Treatment Recommendations to conserve critical healthcare resources, creating a tiered framework for prioritizing services.

The document highlights CMS’ Key Considerations:[4]

• Current and projected COVID-19 cases in the community and region
• Ability to implement telehealth, virtual check-ins, or remote monitoring
• Supply of personal protective equipment available at the practice location and in the region
• Staffing availability
• Medical office/ambulatory service location capacity
• Testing capability in the local community
• Health and age of each patient and their risk for severe disease
• Urgency of the treatment or service

Tier 1, described as a low acuity treatment or service, patients and doctors should consider postponing service.[5]  Examples of Tier 1 are routine care, preventative care/screening, annual wellness or welcome visits, acupuncture, supervised exercise therapy.[6]

Tier 2, intermediate acuity treatment of service – not providing service has the potential for increasing morbidity or mortality, should consider initial evaluations via remote/telehealth with redirection to appropriate sites of care as necessary and follow-up via telehealth if there are no current symptoms of concern[7].  Examples of Tier 2 include pediatric vaccinations, management for existing medical or mental/behavioral conditions, evaluation of new symptoms/concerns in an established patient, and the evaluation of non-urgent COVID-19 symptoms[8].

Tier 3, high acuity treatment or service – lack of in-person treatment or service would result in patient harm, are not recommended to postpone treatment, evaluation, or care, and should be triaged appropriately, as necessary.[9]

AMERICAN COLLEGE OF SURGEONS (ACS)

On April 17, 2020, ACS released “Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic“ as a joint statement with the American Society of Anesthesiologists, the Association of periOperative Registered Nurses, and the American Hospital Association.

Noting that readiness to resume operations will vary by location, ACS and the associated organizations created eight guiding principles and considerations for providers to use in their resumption of care.[10]

Both facilities, facility managers, and practitioners may find the level of detail and perspective in the ACS release helpful.  The guidance details not only use of Personal Protective Equipment (PPE), testing, risk mitigation, and timing of reopening, but also case prioritization and scheduling, post-COVID-19 issues for the five phases of surgical care, and the collection and management of data – an increasingly important consideration for modern healthcare.[11]

In addition to the joint statement guidance, ACS also released the same day Local Resumption of Elective Surgery Guidance to “help local facilities plan for resumption of elective surgical care.”[12]  This goes into even more detail on how local operations can adjust for both COVID and non-COVID care.

NEW JERSEY

On Friday, May 15, 2020, Governor Phil Murphy executed Executive Order No. 145 allowing for the resumption of elective surgeries, both medical and dental, starting Tuesday, May 26 at 5:00 a.m.

The Order required the New Jersey Department of Health (NJDOH) and the Division of Consumer Affairs (DCA) to issue policies to address where, when, and how these surgeries can resume.[13]

Presently, NJDOH issued its guidance on the resumption of elective surgeries in hospitals and licensed ambulatory surgery centers.  DCA issued guidance addressing the resumption of (1) medically necessary or therapeutic services and (2) elective procedures in the office setting.  Both guidance documents are similar in many respects, but the NJDOH’s guidance for performing elective procedures in licensed ambulatory surgery centers (ASCs) adds several requirements.[14]

MINNESOTA

On Tuesday, May 6, Minnesota Governor Tim Walz announced that he would lift the prohibition on elective surgeries.[15]  The guidance released by the state noted that “the Minnesota Department of Health (MDH) recognizes that many elective surgeries and procedures, including dental procedures and veterinary care, cover a wide range of conditions and are necessary to treat chronic conditions, prevent disease, cure disease, prevent its progression, relieve chronic pain, and meet other subacute needs where there is a substantial risk in extended delays to providing care.”[16]

The new guidance also notes that any procedures requiring the use of PPE and ventilators must comply with not only the requirements of the new guidance but also Minnesota Executive Order 20-51.

Minnesota guidance covers community considerations, screening and testing, patient considerations, PPE, and supplies, as well as infection prevention.

ILLINOIS

As of May 11, 2020, hospitals and ASCs can resume elective procedures, provided that they meet the required criteria set forth by the new guidance.  Illinois released expansive guidance that is available not only on the Illinois Department of Public Health (DPH) website but also by PDF.  The guidance covers five areas: outpatient, inpatient, regional requirements for elective inpatient procedures, facility requirements for any elective procedure, and pediatric procedures.

In addition to the detailed guidance released by the state, DPH also issued Q&A pages aimed at both healthcare workers and local health departments.[17]

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[1] https://www.cdc.gov/coronavirus/2019-ncov/hcp/framework-non-COVID-care.html

[2] Ibid.

[3] Ibid.

[4] https://www.cms.gov/files/document/cms-non-emergent-elective-medical-recommendations.pdf

[5] Ibid.

[6] Ibid.

[7] Ibid.

[8] Ibid.

[9] Ibid.

[10] https://www.facs.org/covid-19/clinical-guidance/roadmap-elective-surgery

[11] Ibid.

[12] https://www.facs.org/covid-19/clinical-guidance/resuming-elective-surgery

[13] https://nj.gov/governor/news/news/562020/approved/20200515i.shtml

[14] https://nj.gov/governor/news/news/562020/approved/20200519b.shtml

[15] https://www.startribune.com/minnesota-elective-surgeries-care-to-resume-next-week/570216302/

[16] https://www.health.state.mn.us/diseases/coronavirus/hcp/guidesurgery.pdf

[17] https://www.dph.illinois.gov/covid19/community-guidance/elective-surgeries-and-procedures-faqs