Electing a Path Back to Operational Normalcy

Good fortune smiled on Jennifer Wyche earlier this year.

The bespectacled Ohioan was scheduled to undergo knee replacement surgery in late winter, at the very start of COVID-19’s assault on America. Much of society was still operating normally then, though there were whispers that drastic changes were in store for the planet’s third-most populated country.

Among those changes was widespread business and school closings, social distancing measures, shelter-in-place orders, and—of particular interest to Wyche—suspension of “non-essential” elective surgeries like colonoscopies, endoscopies, non-critical angioplasties/transplants, and hip, knee, and spine procedures.

Naturally, Wyche didn’t want to postpone her procedure; the pain had already become too much to bear. Nevertheless, as the virus began making itself known in the United States, Wyche began preparing herself for a long, painful, uncertain future.

Luckily, that future never came to pass. Wyche received her new knee during the waning weeks of normalcy in the United States, before hospitals resembled war zones and personal protection equipment (masks, face shields) became as rare a commodity as hand sanitizer.

“I can’t imagine, I’ve thought many times, people that have had to stop these surgeries because of the pandemic we have now,” Wyche told Cincinnati’s WLWT5 for the television station’s April 23 broadcast. “I probably would have been in tears if I would have had to wait.”

Hollyanne Fricke certainly felt like crying after her hip surgery was postponed indefinitely a week beforehand. The 32-year-old runner had spent weeks preparing for the procedure, both mentally and physically, dutifully packing her freezer full of soup, lasagna, and breakfast sandwiches. The deferral dashed the Omaha resident’s hopes of participating in her first Boston Marathon, now being held in September due to the COVID-19 pandemic.

“It’s been a roller coaster,” Fricke told Runner’s World for the magazine’s April 1 edition. “I’m able to exercise a little bit, though definitely not to the extent I’d like to. And I’m pretty much in pain all the time. That part sucks more than any of the rest of it.”

Fricke will likely have to endure the pain for the foreseeable future, as elective surgeries are still on hold in most states. Fricke and countless other victims of hastily-cancelled procedures are now living in limbo waiting for guidance on escaping their personal abyss.

With hospitalizations peaking in many outbreak hot spots and states beginning to ease stay-at-home orders, politicians and public health officials are beginning to plot strategies to resume elective surgeries. Many state leaders are following guidelines developed by various groups, including the American Hospital Association (AHA), American College of Surgeons (ACS), the Centers for Medicare and Medicaid Services, and the Centers for Disease Control and Prevention, among others.

In deciding whether to allow elective surgeries to resume, states must balance patient needs with safety and equipment requirements, ensuring the procedures do not encroach on hospitals’ COVID-19 resources.

The roadmap to resuming elective surgeries published on April 17 by the AHA, ACS, American Society of Anesthesiologists, and the Association of periOperative Registered Nurses details the principles and considerations healthcare professions must bear in mind when integrating more elective procedures. Under the groups’ guidelines, facilities should not resume elective procedures without a sustained reduction in new COVID-19 case rates in the area for at least 14 days. Facilities also should ensure they have adequate numbers of trained staff and supplies, including personal protection equipment, beds, ICU, and ventilators to treat non-elective patients without resorting to a crisis-level care standard.

Four days after the AHA and Co.  roadmap came out, the American Academy of Orthopaedic Surgeons (AAOS) released its own guidance specifically for physicians treating musculoskeletal conditions (most of which fall under the “elective surgery” umbrella).

The AAOS clinical considerations cover COVID-19 testing, risk stratification, telehealth services, as well as in-person services and resuming elective surgery. They note that orthopedic surgeons should continue to follow federal, state, and local public health guidance and were formed with the following five principles:

1. The safety of patients must be of the highest priority when considering the provision of healthcare services, items and procedures during the COVID-19 pandemic.

2. The safety of healthcare personnel and staff should be of next highest priority, after accounting for patient safety, when considering the provision of healthcare services, items and procedures.

3. Adhere to CDC and relevant federal, state and local public health guidance and recommendations; the safety of patients and staff members is paramount.

4. Decisions should be locally based, as factors vary by locale; this includes incidence, prevalence, patient and staff risk factors, community needs, and resource availability (to include intensive care unit (ICU) beds, hospital beds, ventilators, and personal protective equipment (PPE)).

It is imperative to accurately determine if the disease burden curve trajectory in your local community is increasing, flattening, or decreasing, as well as the reproductive number; greater than, equal to, or less than one.

5. Follow legal restrictions: many states and locales have mandated shutdowns and stay-at-home orders; it is important to adhere to these legal requirements. v