Elective surgeries continue at some US hospitals during coronavirus outbreak despite supply and safety worries

Jayne O'Donnell | USA TODAY

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U.S. hospitals face a critical shortage of protective equipment and top federal officials have called for a halt to non-emergency surgeries amid the coronavirus pandemic. But some hospitals are ignoring the directive, raising concerns that patients and medical staff are at risk.

Hospitals including University of Pittsburgh Medical Center, Virginia Hospital Center in Arlington and Jackson Memorial Hospital in Miami as of Friday afternoon were still performing elective surgeries, such as for orthopedic problems, cataracts and other non-essential medical issues. Nearly 300 doctors, nurses and other UPMC employees signed a letter that went to members of management last night urging the health system to "postpone procedures that can be performed in the future, and prepare for the influx of patients that will urgently need our care in the coming weeks."

Elective surgery is a medical procedure scheduled in advance because it does not involve an emergency. Frequently, they are not a medical necessity. Examples include knee replacements or nose jobs.

Dr. Linda Alvarez, secretary-treasurer of the Service Employees International Union Committee on Interns and Residents, said medical residents across the country have contacted her with complaints that their hospitals are still performing procedures that aren't essential.

"What is crazy too is that these same residents are saying there is limited availability of N95 masks," said Alvarez, referring to the special masks that can protect against contracting COVID-19, the illness caused by the virus. "To be using this personal protection equipment in ways that are not judicious or addressing the concerns of the general public safety is appalling."

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The U.S. reached more than 278 deaths and over 23,000 confirmed cases Saturday, according to the Johns Hopkins University data dashboard. The global death toll now exceeds 12,000, with almost 300,000 confirmed cases.

Pennsylvania, which announced its second death Saturday, had 371 confirmed COVID-19 cases, 31 of them in Pittsburgh's Allegheny County. When asked Friday about performing elective surgeries, University of Pittsburgh Medical Center's Dr. Graham Snyder told reporters his area is one of "relative calm."

"The health center's job is to take care of patients, not to put them at risk,” said Snyder, UPMC’s medical director for infection prevention and hospital epidemiology. “We are not northern Italy. We are not Wuhan right now. Taking the level of risk in our community, we have to balance that while still providing care."

Some states have reported few cases, but that's because of the slow pace of testing, experts say, and many more are thought to be infected. Federal officials say masks, gowns and other protective equipment, along with ventilators, should be conserved for medical staff and an expected onslaught of coronavirus patients.

Hospitals already are reporting supply shortages. Space also is a looming issue. While many elective surgeries don't require overnight stays, many do, especially if there are complications.

Nearly two out of three of U.S. hospital beds may already be in use, a report out Friday from the Urban Institute and Robert Wood Johnson Foundation found. The analysis of the country's 728,000 hospital beds also showed availability of unoccupied beds per 1,000 people varied significantly across urban and rural areas, states and counties across the country.

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A USA TODAY analysis out last week showed if the nation sees a major spike in COVID-19 patients, there could be almost six seriously ill patients for every existing hospital bed.

Vice President Mike Pence, who heads the White House's Coronavirus Task Force, asked hospitals last week to stop doing elective surgeries and reiterated the call Wednesday at a White House news conference. The same day, the Centers for Medicare & Medicaid Services issued "voluntary recommendations" for elective surgeries to encourage cancellation of non-essential procedures until the COVID-19 outbreak is past.

"We're asking every American, and our medical community leaders, and hospitals to partner with us in delaying elective procedures across the country and our healthcare system to ensure that medical supplies and medical capacity go where they're needed," said Pence.

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In addition to those concerns, Alvarez noted the procedures create yet another patient who is at higher risk for contracting COVID-19 because having surgery suppresses the immune system. (People with chronic health conditions and those older than 60 also are at higher risk of contracting the illness with serious symptoms.)

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Surgeon General Dr. Jerome Adams and the American College of Surgeons also have asked hospitals to stop elective procedures. Adams' office issued a statement to USA TODAY saying its request was "in sync with current CDC recommendations for healthcare facilities."

“Dr. Adams and the President’s Coronavirus Task Force have encouraged healthcare facilities to consider rescheduling non-urgent outpatient visits and elective surgeries, as necessary, due to the demands on our healthcare system during the COVID-19 pandemic," said the statement. "We’re facing an unprecedented threat and it’s important we preserve critical hospital resources, like PPE and staff to ensure an adequate response to the COVID-19 outbreak.”

Hospital associations have pushed back against blanket recommendations. The American Hospital Association said such decisions "should be determined at the local, community level in consultation with hospitals and the clinical recommendations of physicians and nurses."

"It is important to recognize the definition of ‘elective’ procedures includes important life saving measures that will continue to be necessary," AHA said in a statement.

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University of Southern California Medical Center in Los Angeles, one of the last major hospitals in the state still doing elective procedures, announced Thursday "many elective inpatient and outpatient surgeries will be rescheduled on a case-by-case basis." Spokeswoman Meg Aldrich said that means no elective procedures will be performed, but did not know when the policy was effective.

Jimmy Lewis, CEO of the rural hospital group Hometown Health based in Georgia, said less than 5% of his members are still doing elective surgeries, though he added most are acute care hospitals that do few such procedures.

"They stopped doing it unless they looked at a facility to see if a certain operation could be fit in without exposing other patients," Lewis said. "If you decide to do one $5,000 surgery, you have to do an analysis of having a contaminated patient come into the hospital versus the $5,000."

Lewis tells members it isn't worth it because of the "obvious ethical" issues, along with the "fear of liability." If hospitals decide to do an elective surgery, and a patient dies of coronavirus, plaintiff attorneys will come in later.

"They're going to ask, 'Why did you do an elective surgery that killed momma?'"

Five people who work at hospitals spoke on condition their names and employers not be used, but USA TODAY confirmed with hospitals the status of their elective surgeries.

Hospitals still performing elective surgeries as of Friday included:

• University of Pittsburgh Medical Center. Some facilities had busy elective schedules Friday and physicians were performing hernia repairs, cataract surgeries and orthopedic procedures known as scopes that involve small incisions to view and repair joint problems, according to two health care workers at the health system.

"Balancing our patients’ ongoing clinical needs with the avoidance of unnecessary exposure requires a nuanced approach – not an across-the-board cancelling of clinics and procedures," UPMC said in a statement Friday.

"We continue to serve our patients whose procedures our clinicians believe are not medically responsible to delay. Our careful triaging of upcoming elective procedures on a case-by-case basis meets the Centers for Medicare & Medicaid Services guidance.

"We have a multidisciplinary team of experts closely monitoring the situation and will adjust accordingly."

UPMC's Children's Hospital was doing elective dental procedures on Friday. CMS targeted dental procedures in its recommendations Wednesday because they always require "personal protective equipment" that's in short supply and because they "have one of the highest risks of transmission due to the close proximity of the healthcare provider to the patient."

• Virginia Hospital Center. The Arlington-based hospital on Friday had many patients recovering after elective surgeries, according to three people who work at the hospital and asked that their names not be used for fear of retribution. Every other hospital in the Washington, D.C area had stopped the procedures, a USA TODAY review found.

"Virginia Hospital Center is still performing elective surgeries," said spokeswoman Anne Kelsey. "While nationwide shortages exist, we have not had any reason to deviate outside of those guidelines."

Kelsey added the hospital is being "cautious and mindful about the allocation of all of our resources."

Saturday night, several hours after this article posted, VHC spokeswoman Maryanne Boster emailed a "clarification of the answer," that restated that it is using cautito allocate resources. She added VHC has "rescheduled most elective procedures. However, some procedures cannot be postponed, including those such as cancer cases involving tumor removal or biopsies."

USA TODAY confirmed some surgeries taking place on Friday and scheduled this week were neither cancer-related nor urgent medical needs. Meanwhile, the medical staff is reusing the N95 masks that protect against COVID-19, using cleaning rags with bleach-based solution instead of disposable bleach wipes, reusing masks after dealing with patients and not getting masks at all unless they have face-to-face contact with patients, according to two of the hospital workers.

• Jackson Memorial Hospital. The trauma hospital is based in Florida's Miami-Dade County, which now has the highest number of deaths in the state, with more than 100. The hospital said in a statement to USA TODAY Friday afternoon that "physicians have been given some discretion as to whether to cancel or proceed."

The hospital was "continuing to perform all emergent and urgent surgeries, procedures, and clinic appointments for now," the statement said.

At 7 p.m., more than three hours after Gov. Ron DeSantis issued an executive order requiring all "nonessential medical procedures be postponed," the hospital said it was "immediately complying with this order."

Jackson also said it has "sufficient PPE on hand for current and anticipated volumes," and "have enough ventilators and have rented additional to be prepared for future demand. We also have open orders to secure even more."

Alvarez said hospitals that have so much protective gear that they can afford to do elective surgeries should consider sharing with less well supplied hospitals. "I think hospitals should assess their communities, and the impact they are expecting to face not only in their area but in the surrounding areas as well, and use this to appropriately plan their need for PPE," said Alvarez. "It is also important now, more than ever, we come together in the medical community to promote patient and worker safety."

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