SAN FRANCISCO, CA – In the same week that physicians at the University of California-San Francisco medical center were wiping down and reusing protective equipment like masks and gowns to conserve resources amid a surge of COVID-19 patients, 90 miles away teams of doctors at UC Davis Medical Center were fully suited up performing breast augmentations, hip replacements and other elective procedures that likely could have been postponed.
Across the nation, hospitals, nurses and physicians are sending out desperate pleas for donations of personal protective gear as supplies dwindle in the regions that have emerged as hot spots for the fast-spreading new coronavirus. The Centers for Medicare & Medicaid Services, the Surgeon General and the American College of Surgeons (ACS) have urged hospitals to curtail non-urgent elective procedures to preserve equipment. Washington state, Colorado, Massachusetts, Ohio, Kentucky, New York City and San Francisco have gone further, placing moratoriums on elective surgeries.
Still, in pockets of the country, some hospitals have continued to perform a range of elective procedures, spokespeople confirmed. In Pennsylvania, the University of Pittsburgh Medical Center is continuing to offer elective procedures on a case-by-case basis. In Indiana and Illinois, Franciscan Health will continue some elective surgeries, depending on the availability of protective equipment and the concentration of COVID-19 cases in the area. And in California, Nebraska, Nevada and Wyoming, Banner Health will continue to offer elective procedures in communities that haven’t yet reported cases of COVID-19.
The divergent responses underscore not only the disparities in supply stockpiles from hospital to hospital, but also a lack of coordination — even at a regional level — in getting equipment and medical care where it’s needed.
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Gerald Kominski, a professor at the UCLA Center for Health Policy Research, was among the experts interviewed who found it troubling that hospitals would continue to perform elective surgeries in the face of the coronavirus threat, both because of the toll on scarce national supplies and because it puts staff and patients at unnecessary risk of exposure.
“It seems unconscionable, regardless of the motive, in my judgment,” Kominski said. “[Hospitals] are ignoring the restrictions on unnecessary public interactions, placing their staff and patients at greater risk.”
One study out of Wuhan, China, for example, found that 41% of the COVID-19 infections in a group of 138 patients were acquired at a hospital. In Italy, health care workers represent 8.3% of COVID-19 cases.
Some experts said they could understand the reluctance to shut down elective surgeries. Hospitals rely on these lucrative procedures to stay afloat in an industry that often operates with narrow margins.
“Hospitals maybe shouldn’t do elective surgeries because it’s not in the public interest. But there’s the immediate problem of ‘How will I pay my staff if I can’t do all these lucrative surgeries? I don’t want to lay them off at a time of crisis,’” said Leemore Dafny, a Harvard Business School professor who studies the health care industry.
Elective surgeries cover a broad range of procedures, from pressing interventions such as removing a cancerous tumor, to those that are truly optional, such as cosmetic procedures. Several hospitals said that they have cut back on such procedures but that the response is nuanced and they are proceeding case by case after assessing which surgeries can be safely delayed.
California offers a prime example of the disparate responses. The state has been an early epicenter for the new coronavirus, with more than 1,000 confirmed cases and nearly two dozen deaths. The San Francisco Bay Area has been hit particularly hard, and emergency room doctors at UCSF this week described dire shortages of personal protective equipment, or PPE. Sutter Health has shut down elective surgeries, as have most other University of California hospitals across the state.
At UC Davis, in contrast, procedures have continued.
“I’ll be clear: There is no reason to cancel elective procedures at this time and doing so would be a disservice to our patients who, for many different reasons, require surgery or other scheduled procedures,” UC Davis Chief Medical Officer Dr. J. Douglas Kirk wrote in an email to employees earlier this week. “We currently have capacity and we have an outstanding supply chain and procurement team, so the UC Davis Medical Center is doing well on supplies, PPE and space utilization.”
On Monday, March 16, two of the hospital’s operating rooms were dedicated to cataract surgeries and another to lifting droopy eyelids, according to a doctor with access to the daily surgical schedule. Physicians also performed two gastric bypasses, a type of weight-loss surgery. On Tuesday, there was a hernia repair and a cochlear implant. On Wednesday, surgeons inserted breast implants in one patient and removed a nonmalignant mass from another. On Thursday, there appeared to be fewer elective procedures, but surgeons did a new hip replacement and revised another.
“It’s frustrating because this doesn’t appear to be a decision in the best interest of the patients or the providers,” said one UC Davis physician who works in perioperative services and asked that his name not be used for fear of job repercussions. “Many of my colleagues have protested, but they’re falling on deaf ears.”
Like Kominski, the physician said he worries that the procedures pose an unnecessary risk of coronavirus transmission for the patients undergoing elective surgery, the staff and other people in the waiting room. These risks are worth taking in an emergency situation, he said, but not if a procedure could be safely delayed.
He said doctors are using surgical masks rather than N95 respirators with patients, unless COVID-19 is strongly suspected or the patient has tested positive. But given that COVID-19 is thought to be widespread in Sacramento County, where the medical center is located, and asymptomatic people may be contagious, he worries he could still become infected. If the hospital’s N95 supplies are robust, he wondered, why are they not using the more protective masks with all patients?
Another UC Davis physician, who also asked that her name be withheld, said she is “bewildered” as to why the hospital would continue offering procedures that the ACS and federal government recommend halting.
“You’re specifically harming the people you’ll need if this becomes very, very bad,” she said. “People who make these decisions will never have a patient cough in their face. They’re demanding we take all the risk when they get paid significantly more to sit in isolation teleworking.”
And if the hospital really does have excess stores of N95s, “we should be sharing if everyone else is down supplies,” she added.
In an email, UC Davis spokesman Charles Casey wrote that the hospital’s patients tend to be sicker and the cases more complex, and that staffers are continuing to provide essential services “because we have the supplies and the space to safely do it. In the meantime, we are evaluating the situation on a daily basis and are maintaining the flexibility to change as soon as needed.”
Industry officials noted that not all surgeries labeled as elective can be safely delayed. “If these types of procedures are delayed or canceled, the person’s condition gets rapidly worse and can even be life-threatening,” the American Hospital Association and other industry groups wrote in a letter to the Surgeon General. For patients, the delay of a long-awaited surgery may be devastating.
Still, Dr. Alyssa Burgart, a bioethicist at the Stanford Center for Biomedical Ethics, said the threat coronavirus represents to the U.S. health care system calls for an unprecedented response, and hospitals across the country need to brace now.
“We’re watching this disease burden health care systems in other countries in an exponential fashion,” she said. “I think these hospitals will look back and wish they had acted sooner.”