The COVID-19 pandemic severely disrupted routine US health care delivery including elective and urgent specialty care.1 Health systems' response to managing surgical disease during the pandemic is requiring dramatic paradigm shifts from standard approaches to surgical care. The early and immediate need to preserve personal protective equipment (PPE), redeploy staff to testing centers and intensive care units (ICUs), implement social distancing measures, and add screening protocols for patients and staff safety has limited space and resources, leading many health care organizations to postpone elective surgical procedures. During the 12-week period from March to May 2020, an estimated 4.1 million elective surgical procedures were cancelled in the United States, with time predicted to address the elective surgical backlog ranging from 30 to 90 weeks.2 The effect of these delays on patient quality and safety is unknown.3
Health care organizations are taking a mix of approaches. Many systems have postponed all elective operations, whereas some have tried to maintain normal surgical workflow or some combination of actions. The very definition of time-sensitive versus elective surgery varies significantly, which also influences their response. Intermountain Healthcare has not been immune to these challenges. Intermountain leadership introduced several mechanisms to address patient needs as safely and effectively as possible. As an aspiring learning health system, Intermountain is also using data to learn from what we are doing to change the way we deliver surgical care during and even beyond the current pandemic.
First, to enable a strategic, coordinated response to the pandemic, Intermountain operationalized a system-wide hospital incident command system (HICS). This staged surge response plan included phased staff redeployment and increased ICU capacity by converting medical-surgical floor and postanesthesia care unit beds into ICU beds. Surgical leaders worked closely with the HICS to ensure bed capacity, safeguard the downstream supply chain, and manage the workforce when directing surgical operations. Surgical specialties leadership developed guidelines for managing surgical conditions with limited resources and created a priority list of conditions based on the Centers for Medicare & Medicaid Services tiers and the American College of Surgeons recommendations.4 The prioritized list defined appropriate cases consistent with the state of Utah's color scheme described in Table 1. Each of Intermountain's 23 hospitals' OR Councils worked with surgeons to timely accommodate indicated operations as the risk of delay to individual patients was weighed against available hospital and system resources.
Elective surgical procedures postponed. On March 15, 2020, in response to SARS-CoV-2 spread in Utah, Intermountain's Executive Leadership Team suspended all elective operations. From March 16 through May 31, while transitioning through the color phases from Red to Green, Intermountain performed 20 779 operations and procedures, which was 28 808 fewer than were performed in the same period in 2019 (Table 2). A total of 11 085 patients were scheduled for a surgery that was postponed. Thousands were never scheduled. At this writing, surgical volume is not restricted by government or system policy, even as Utah's COVID-19 case counts rise. Capacity at individual hospitals is limited by health care worker supply and continued assessment of system and facility bed capacity, supplies, and resources.
Finally, the intense response to COVID-19 creates a unique opportunity to study the outcomes of patients with postponed surgery and forge innovative solutions to improve value in delivering perioperative care. For some patients, delayed surgery may have caused harm.5 For instance, children unable to obtain tympanostomy tubes could acquire hearing loss, delays in speech and language development, and Clostridium difficile infection from multiple antibiotics. Patients awaiting cholecystomy could progress to gangrenous cholecystitis. We have identified several areas we plan to study where delays in surgery may have catalyzed innovative approaches to more efficient and coordinated care while ensuring patient and staff safety.
Surgery delays may provide opportunities to better address comorbid risk factors, enabling primary care providers (PCPs) and surgeons to cooperatively work to "prehabilitate" patients optimally for surgery. With the reopening of elective procedures, a screening questionnaire for each patient submitted by the surgeon was implemented on April 24, 2020. This questionnaire addressed comorbidities and evidence-based risk factors that might lead to poor patient outcomes or excessive resource utilization. Use of the survey is currently informing decisions to timely deliver surgical care. Beyond the pandemic, this process could be used in a surgical home to preoperatively assess and mitigate patient risk factors to prehabilitate patients with comorbidities before undergoing surgery.
Postponed surgical procedures may have enabled better decision-making for some patients to permanently decide against surgery, shifting clinical equipoise and highlighting opportunities where nonsurgical options may be equally effective. As some patients waited months for their operation, some conditions may have resolved or the risks outweighed the benefits over time. These experiences can inform patients when watchful waiting or nonsurgical intervention is appropriate.
Expanded use of telehealth may identify effective utilization of this technology in perioperative care.6 Prior to the pandemic, Intermountain-employed physicians conducted a mean of 5 virtual video visits daily. When nonurgent in-person clinic visits were restricted, 117 115 video visits were scheduled, and now video visits average approximately 3200 daily. Rapid adoption of this technology can be investigated to highlight opportunities for sustained usage of telehealth, including leveraging telehealth to improve coordination of perioperative care.
Throughout the pandemic, ensuring patient and hospital staff safety remains the top priority. Routine preoperative testing for the COVID-19 virus in patients undergoing aerosol-generating procedures was implemented on April 16 and then expanded to all surgical patients on April 26. As of June 4, the incidence of a positive test in asymptomatic patients screened for surgery was less than 0.002 (17/9421). PPE guidelines for staff and preoperative testing protocols continue adjusting to disease prevalence in our communities.
LOOKING AHEAD
This unprecedented environment, with nearly 30 000 operations postponed in our system, allows us to study the impact on patient outcomes for elective surgical conditions when surgery is delayed. Preoperative viral testing is performed to keep patients and health care workers safe. Innovative value-based interventions discovered during the pandemic response will be implemented and tested, including but not limited to (a) coordinated telehealth shared decision-making consultations with surgeon, PCP, and patient; (b) prehabilitation protocols for patients with complex chronic conditions; and (c) new uses of virtual visits in the perioperative setting.
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