Austin Wall left work with severe pain and knew something was not right.
Wall, 42, a Caterpillar dealership parts coordinator in Irving, Texas, went to an urgent care clinic nearly a month ago and was quickly sent to the Medical City Hospital in Arlington -- his kidney stones were causing problems in his digestive system and his right kidney was functioning at a loss.
While his doctors were able to put a stent into his left kidney, they were unable to perform laser surgery to break up the large stone in his right one because of Texas Gov. Greg Abbott’s March 22 executive order postponing all surgeries that were not “immediately, medically necessary to correct a serious medical condition or to preserve the life of a patient.”
Instead, the doctors sent Wall home with a catheter. He continued to work for several weeks before being placed on short-term disability because the stent and catheter prevented him from lifting more than 10 pounds. As Wall awaits surgery, his daily routine has been disrupted by the catheter and stent.
“When he wants to take a shower, we have to put a shield over his back where that tube is coming out of his kidney, so that it doesn't get wet,” Austin’s wife, Jessica Wall, said. “We have to change the bandage every so often because from sleeping and sitting and just, you know, everyday moving, it causes the bandages to move, so we’re constantly having to change those bandages. He constantly has to drain the urine from the bag, and we have to flush the bag out.”
She said that Wall also feels as if he constantly has to urinate, but has little success. “I kind of laugh and tease and say, now he knows what it's like to be pregnant," she said.
Austin Wall is also a 17-year brain cancer survivor, which his wife said probably makes him a part of the immune-compromised category. He has had a number of health problems in recent years, including seizures. Jessica Wall said that a possible side effect of his seizure medicine is kidney stones.
“It's super frustrating, you know, knowing that this surgery is absolutely needed for him and because of where we are in the world right now with the coronavirus, everything is at a halt,” Jessica Wall said. “This surgery seems so simple to us, you know, but it's so needed for him. You can't just pick up the phone and say, ‘Hey, we're ready to have this surgery.’ We have to wait.”
As COVID-19 has spread across the country in recent months, hospitals have postponed elective surgeries, nonemergency procedures such as Wall's that are scheduled in advance. Cosmetic surgery, hernia repair and cancer operations are among the wide range of elective surgeries that come with varying degrees of complexity and urgency.
The American Hospital Association published a road map to resuming elective surgeries on April 17, alongside the American College of Surgeons, American Society of Anesthesiologists and the Association of periOperative Registered Nurses.
The road map details principles and considerations for health care professionals to take into account as they start integrating more elective procedures back into their schedules. Some of the principles include timing for reopening elective surgeries, COVID-19 testing within facilities, adequate Personal Protection Equipment (PPE) supplies, conservation policies for PPE and case prioritization and scheduling.
Across the board, hospital revenues in March were down 13 percent from the same month last year, according to an April financial report by Kaufman Hall, a health care consulting firm.
By late April, more than 30 governors had issued executive orders banning or postponing elective surgeries, while others have left the decision up to the individual hospitals. Governors from more than a dozen states have loosened restraints to allow some degree of elective treatments to start again in the coming weeks.
Resumption of elective surgeries is a part of President Donald Trump’s “Reopening America” plan. “We’re encouraging states around the country to restart elective surgery wherever possible even on a county by county basis," Vice President Mike Pence said Friday, speaking at Trump's signing of a $484 billion coronavirus relief package.
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As states gauge whether to allow elective surgeries, surgeons and hospitals face the difficult task of balancing patients' needs with safety and equipment requirements. Postponing elective surgeries has also allowed hospitals to conserve personal protective equipment (PPE) and hospital beds for care involving COVID-19 patients.
“Coronavirus is highly infectious, and if there's a procedure that would bring people together, just like in a restaurant or an airplane, then avoiding it if it can be avoided is the best practice,” Dr. David Hoyt, executive director of the American College of Surgeons, told NBC News. “You have to balance that with patients that need surgery, but the urgency of it can be triaged, and that's what was done.”
Some surgeons have also shared concerns about performing elective surgeries on asymptomatic COVID-19 patients, fearful that patient mortality and ICU rates can increase significantly for those with unknown infection at the time of surgery.
Hospitals that resume elective surgeries need to be mindful of maintaining beds and equipment in case there are an uptick of sick patients, Hoyt said. “I think people need to ramp up at some rates, not just do it all overnight.”
Most hospitals have come up with systems to assess the urgency of elective surgeries for their patients.
“We've continued to do urgent cases,” Dr. Elizabeth Wick, a professor of surgery at University of California San Francisco, said. “If they start to have symptoms, we've tried to keep a close eye on our backlog. All the cancer patients that we’ve postponed have been discussed in the tumor board with a multidisciplinary group.”
Surgeons at the University of California San Francisco hospital -- in the same region as the country's first known COVID-19-related death, on Feb. 6 -- devised a triage plan in early March to determine the urgency of elective surgeries. Their plan includes establishing strong leadership and communication across departments, details on ensuring hospital capacity and the equipment needed as well as preparations for an unstable workforce environment. According to the study, the staff was able to reduce their operating room volume by 80 percent under this system.
The hospital in April also began implementing preoperative testing and screening for patients undergoing surgery.
“We expect that the vast, vast, vast majority of our patients will continue to be asymptomatic, COVID-negative, even after we implement this,” Wick said. “So, it’s just an extra reassurance that you know it's safe to proceed with surgery.”
Wick also said that there is a large backlog of patients in the hospital and that it was unclear when exactly patients with lower-risk procedures will have them. She said that process will involve lots of reassurance and explanation to patients in the coming months.
“Some of those lower priority cases, patients with lower priority conditions, aren't wanting to come to the hospital, particularly with the visitor restrictions and other things in place,” Wick said. “I think it's going to take a lot of thought and working with the patients to sort of work through that backlog.”
A systematic approach
The University of Chicago hospital published a scoring system this month to aid surgeons in making decisions about elective surgeries. The “Medically Necessary Time-Sensitive (MeNTS) Prioritization” system allows surgeons to assess elective surgeries systematically -- evaluating risks for both patients and personnel.
“While these numbers are not meant to be strict cutoffs, as far as if it's above some number, then you can't do it and below it, you can, that sort of thing, it at least provides guidance,” Dr. Vivek N. Prachand, professor of surgery and chief quality officer for surgery at University of Chicago, said.
Prachand said that this will provide some guidance and then the threshold of whether to do the surgery can be decided, “not only the score, but the availability of the resources and personnel in the hospital itself, depending on where it's located, not only geographically but where it's located along the COVID curve.”
Dollars and sense
Elective surgeries bring in a great deal of revenue for hospitals, and as the pandemic persists, hospitals have begun to see the financial impact of postponing them. A number of hospitals have laid off or furloughed staff, or cut pay to make up for the losses. The Henry Ford Health System in Detroit announced Wednesday it was furloughing approximately 2,800 employees. University Hospitals in Cleveland reduced hours and pay by 20 percent for approximately 4,100 staff members.
The Bureau of Labor and Statistics reported a 3.2 percent unemployment rate for education and health care professionals in March, up from 2.3 percent last year, a difference of 195,000 people.
Hospitals were recently allocated $100 billion in federal stimulus funds. A JP Morgan Analysis found that this amount would keep hospitals afloat for two months if hospital revenues were to drop by 50 percent.
Hospitals received $30 billion shortly after the announcement and were supposed to start receiving payments on a weekly rolling basis starting on Friday, April 24.
Location is also a factor for reintroducing elective surgeries. This process will look different for hospitals around the country, based on a number of factors, including population size and the presence of Covid-19 cases in the community.
“I think in a hospital that has slowed down elective surgery that does not have a lot of COVID patients, they're going to be able to ramp up more quickly, and they'll feel a little safer doing so on the short term,” Hoyt said. “But you know, some of them, depending on the locale, may have sent physicians off to help somewhere else. They're just going to have to look at what they have, what the capacity they can create based on what they have and then come up as quickly as possible.”
Along with the road map back to elective surgeries, the American College of Surgeons released recommendations for local resumption of elective surgeries.
There is also a gray area around the long-term outcomes that patients will experience if they do not receive the elective surgeries. The majority of Prachand’s operations are for weight management, and he said that while they all seem to be elective on the surface, there is data that shows some health problems could be avoided if the surgery is completed.
“In the longer term — two years, two and a half years after surgery — it does appear that the benefits of the surgery helps reduce the risk of dying prematurely,” Prachand said. “It certainly reduces the presence of diabetes and high blood pressure and these sorts of things.”
The way that this will affect hospitals in the long term is unclear, but there are several changes to note, including the use of telehealth, a digital resource that allows patients to connect with physicians for information and video chats.
Dr. Carolyn Hettrich, Chief of Shoulder Service at Brigham and Women’s Hospital in Boston, said that 98 percent of her surgeries are elective, so most of her days are now spent having virtual appointments with her patients.
“It's been dramatic across our department that most of our surgeons have seen dramatic reductions in the number of surgeries performed,” Hettrich said.
Hettrich said that while there are positives and negatives about virtual appointments, she is able to still connect with her patients and provide them with knowledge and advice about their pain. The video aspect allows her to see her patients and do limited physical exams -- sometimes asking them to pick up household items, like a gallon of milk, to determine results for strength exams.
“Patients seem to like it,” Dr. Hettrich said. “It allows people to stay in their homes, they stay safe and it's still a way to kind of interact with your patients.”
Hoyt also said that he thinks telecommunication will be enhanced and used more after the pandemic. He also thinks that there will be heightened sensitivity to the potential for future outbreaks as well as “better stockpiles of equipment, more contingency plans for bed availability and more regional sharing of resources.”
“I think there will be a lot of policies that will affect the health care system that will be governed by certainly the government, but also insurers and physicians,” Hoyt said. “So, I think a number of things, mostly good, will come out of this, but right now, we're still doing a lot of learning.”
For Austin Wall, his faith in the Lord is helping him stay positive as he waits for his operation. He expects to continue waiting for his surgery even after restrictions in Texas are lifted. He and his wife pass the time by sitting in their front yard watching “nonexistent” cars pass by and catching some Vitamin D.
“We can either keep life shut down and just worry and have fear and anxiety, or we can choose to trust that when things do open back up, that my husband will be taken care of,” Jessica Wall said.