CMS Sets Phased-In Path to Resume Elective Procedures

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APRIL 20, 2020 -- Federal officials and medical groups are outlining pathways for allowing elective procedures to resume in a phased-in manner when the threat of COVID-19 infection appears to subside in different regions of the United States.

Separately, three governors moved last week to ease restrictions on surgeries in their states.

The Centers for Medicare & Medicaid Services (CMS) on Sunday issued a set of recommendations for allowing elective procedures to resume. That release followed the April 17 announcement about a joint roadmap for eventual resumption of elective surgeries from the American Hospital Association (AHA) and three medical groups: American College of Surgeons, American Society of Anesthesiologists, and Association of Perioperative Registered Nurses.

The CMS plan first requires states or regions to meet specific "gating criteria" before being allowed to consider phasing-in elective procedures. Among them:

  • A downward trajectory of influenza-like illnesses reported within a 14-day period

  • A downward trajectory of documented COVID-19 cases or a downward trajectory of positive tests as a percentage of total tests within a 14-day period

  • A "robust" testing program in place for at-risk healthcare workers, including emerging antibody testing

In its recommendations to healthcare facilities, CMS emphasized a need for careful planning around elective procedures, which includes multiple considerations such as adequate PPE supplies and other necessary equipment, enough testing capacity, proper sanitation protocols, and adequate workforce availability — while remaining ready for potential surges in COVID-19 cases,

CMS suggested hospitals consider establishing what it termed "non-COVID Care (NCC) zones" when declines in the intensity of COVID-19 infections in a region allow for elective procedures.

"Staff who will be working in these NCC zones should be limited to working in these areas and not rotate into "COVID-19 Care zones" (eg, they should not have rounds in the hospital and then come to an NCC facility)," CMS said.

In addition, CMS recommended patients be screened for potential symptoms of COVID-19 prior to entering the NCC unit and that staff for such sections would need to be routinely screened for potential symptoms. Hospitals also would need to maintain adequate staffing levels to cover a potential surge in COVID-19 cases, CMS said.

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CMS also separately on Sunday announced plans to require nursing homes to inform their residents and the representatives of residents about confirmed cases of COVID-19.  

"At a minimum, once these requirements are in place, nursing homes must inform residents and their representatives within 12 hours of the occurrence of a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms that occur within 72 hours," CMS said.

AHA Roadmap

In its joint roadmap, the AHA and its partners addressed similar considerations, such as a sustained reduction in the rate of new COVID-19 cases in a region for at least 14 days before the resumption of elective procedures.

In addition, hospitals should have enough beds, personal protective equipment (PPE), ventilators and trained staff to allow these surgeries to take place with "without resorting to a crisis standard of care," the medical groups said.

"Many patients have had their needed, but not essential, surgeries postponed due to the pandemic," the AHA and partner groups said. "When the first wave of this pandemic is behind us, the pent-up patient demand for surgical and procedural care may be immense, and healthcare organizations, physicians and nurses must be prepared to meet this demand."

Alaska, Oklahoma, and Texas

Governors in Alaska, Oklahoma, and Texas last week announced plans to allow certain elective procedures to resume in hospitals in their states.

Alaska Gov. Mike Dunleavy (R), said he will allow medical services "that cannot be delayed beyond 8 weeks without posing a significant risk to quality of life" to resume May 4 if certain conditions can be met. These include requiring that clinicians can wear surgical masks, eye protection, and gloves for these procedures.

In cases where procedures carry increased risk of COVID-19, such as dental work, a negative polymerase chain reaction (PCR) test for Sars-CoV-2 infection should be obtained within 48 hours prior to the procedure, according to an April 15 mandate signed by Dunleavy.

"The suspension of nonessential procedures and healthcare have been beneficial in slowing the spread of the disease," Dunleavy and other Alaska officials said in the mandate. "The benefits of suspension must also be balanced with delayed healthcare and other health outcomes."

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Oklahoma Gov. J. Kevin Stitt (R) issued new guidelines last Thursday for clinicians outlining which elective surgeries can resume as soon as this Friday. He also signed a memorandum outlining what he called an "elective surgery acuity scale" to guide decisions on these cases. 

"We initially suspended elective surgeries to preserve hospital bed capacity and PPE to handle a potential surge in COVID-19 patients," said Stitt in a statement. "Since our data indicates we are in a good position regarding hospital capacity — and provided individual institutions can accommodate their internal demand for PPE — it is time to bring some of these procedures back to help our hospitals and the Oklahomans who need them."

Certain cancer surgeries were already allowed in Oklahoma, according to Stitt's memo. Beginning Friday, procedures for conditions "that are not life-threatening and which, if not provided, would have the potential for increasing morbidity or mortality" can be performed, according to Stitt's memo.

On May 1, minor medical procedures and nonemergency dental procedures such as outpatient surgeries or procedures for non–life-threatening illnesses may resume.

Texas Gov. Greg Abbott (R) last Friday issued an executive order on COVID-19 that included exceptions to allow for elective surgeries in certain cases.

Abbott's order seeks to limit these procedures such that they will not deplete hospitals' capacity or the PPE supplies needed to cope with COVID-19. His order seeks to limit elective procedures to medical facilities that will certify in writing to Texas officials that they agree to reserve at least 25% of hospital capacity for treatment of COVID-19 patients.

These medical facilities also will need to agree that they "will not request any PPE from any public source — whether federal, state, or local — for the duration of the COVID-19 disaster," Abbott said in the executive order.

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