Federal and Louisiana State Directives on Elective Surgeries and Procedures During the Covid-19 Pandemic Continue to Evolve
Laws and regulations are changing rapidly. After the publication of this article they are subject to change. Check back regularly for updates.
As the current situation evolves during the coronavirus disease 2019 (COVID-19) pandemic, hospitals and other healthcare provides have been faced with rapidly evolving challenges from the broad directives to postpone and delay “elective” surgical procedures. The Centers for Medicare and Medicaid (CMS), healthcare professional boards and several states, including Louisiana, have mandated that elective procedures be put on hold to try to preserve limited resources within the healthcare system and mitigate community spread of COVID-19.
Several concerns and questions have been raised regarding these directives to address the COVID-19 pandemic because of the lack of guidance on complying with these directives. This may be primarily due to the rapidly evolving actions taken to the prevent the spread of COVID-19 and the situation in Louisiana. Other related concerns have been raised regarding the effect of physician practices limiting their hours and accessibility due to government recommendations and increasing demand for non-essential procedures. Such actions could result in additional stress on hospitals as patients’ options for care become more limited.
One evolving option in several states are partnerships between hospitals and ambulatory surgery centers (ASCs) to utilize space, equipment and staff in an ASC to address surge capacity in hospitals for COVID-19 patients. In Louisiana, one option currently being discussed is the possibility of ASCs partnering with hospitals in their communities to develop step down care plans for ASCs to provide a hospital level of care for COVID-19 patients. Depending on how this partnership would be structured, LCH would need to get a 1135 waiver approved by CMS and ASCs could use an Use Agreement or similar agreement that is already provided for in the Louisiana ASC licensing regulations.
Hospitals, physicians and other providers will need to monitor the evolving directives and guidance related to elective medical and surgical procedures, including the types of healthcare facilities where they may be performed.
The following is a summary of current Louisiana directives and a timeline of other guidance and recommendations on elective and non-emergent surgical procedures.
Louisiana Directives (To Date) on Medical and Surgical Procedures
Medical and Surgical Procedures
The LDH recently issued two directives to licensed healthcare facilities and licensed healthcare professionals regarding medical and surgical procedures related to efforts to prevent the spread of COVID-19. LDH issued a directive on March 18th requiring that all medical and surgical procedures be postponed for thirty days that can be safely postponed in the medical opinion and judgment of the physician or other appropriate healthcare professional. However, as the number of patients testing positive in Louisiana for COVID-19 continued to increase, the LDH issued a second directive on March 21, 2020 superseding the March 18th directive, requiring that all medical and surgical procedures shall be postponed until further notice subject to exceptions only for surgical procedures to treat an “emergency medical condition” or “to avoid further harms form underlying condition or disease.”
The following are summaries of the LDH directives regarding medical and surgical procedures:
- On March 18, 2020, the Louisiana Department of Health Office of Public Health issued HEALTHCRE FACILITY NOTICE #2020-COVID19-ALL-006 DIRECTING AND REQUIRING that all licensed healthcare facilities and all healthcare professionals licensed by the Louisiana State Board of Medical Examiners or the Louisiana State Board of Nursing immediately adhere to the following: “any and all medical and surgical procedures that, in the opinion and judgment of the physician or other appropriate healthcare professional acting within the scope of his/her license, can be safely postponed for a period of thirty (30) days.” This 30-day period runs from March 19, 2020 through April 21, 2020.
- On March 21, 2020, the Louisiana Department of Health Office of Public Health issued HEALTHCRE FACILITY NOTICE #2020-COVID19-ALL-006 DIRECTING AND REQUIRING that all licensed healthcare facilities and all healthcare professionals licensed by the Louisiana State Board of Medical Examiners or the Louisiana State Board of Nursing immediately adhere to the following: “any and all medical and surgical procedures SHALL be postponed until further notice” subject to exceptions for medical and surgical procedures to: (1) treat an emergency medical condition as defined in 42 C.F.R. § 489.24; or (2) to avoid further harms from underlying condition or disease.
The LDH March 21st directive also directed all healthcare providers to postpone all in-person healthcare services that can be safely postponed for 30 days, and further directed all healthcare providers to transition all in-person healthcare services to a telehealth mode of delivery.
Dental Visits, Procedures and Surgeries
On March 17, 2020, the Louisiana Department of Health Office of Public Health issued HEALTHCRE FACILITY NOTICE #2020-COVID-19-DENTAL PROVIDER -004 “DIRECTING AND REQUIRING” all providers of dental services (including dentists and hygienists) in Louisiana to adhere to the following: “The State of Louisiana, Department of Health, hereby prohibits all routine, non-essential dental visits and all routine, non-essential dental procedures/surgeries in Louisiana for thirty (30) days from March 18, 2020 through April 16, 2020, unless otherwise extended in writing by the Department.”
Timeline of Other Evolving Guidance and Directives on Elective Surgeries
The following are some notable recommendations and guidance that have e been issued regarding elective surgeries and procedures during the COVID pandemic:
- On March 1, 2020, the Centers for Disease Control and Prevention (CDC) issued an Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States (www.cdc.gov/). The CDC recommended that inpatient facilities reschedule elective surgeries as necessary and shift elective urgent inpatient diagnostic and surgical procedures to outpatient settings, when feasible.
- On March 15, 2020, the American Hospital Association, Association of American Medical Colleges, Children’s Hospital Association and Federation of American Hospitals sent a letter to the surgeon general requesting clarification on the surgeon general’s comments by recognizing the gradients of elective surgeries and offering guidance on how to classify the various levels of necessary care. The associations commented that “elective” simply means that “a procedure is scheduled rather than a response to an emergency,” and could therefore include, for example, replacement of a faulty heart valve, removal of a serious cancerous tumor or a pediatric hernia repair. The associations emphasized that the delay or cancellation of these procedures often rapidly worsens the patient’s condition, potentially turning it into a life-threatening condition and making the patient more vulnerable to COVID-19.
- On March 16, 2020, the Ambulatory Surgery Center Association (ASCA) released a position statement on elective surgeries during the COVID-19 pandemic in which it stated that “ASCs can continue to provide safe surgical care for patients whose condition cannot wait until the health care system returns to normal operations.”
- On March 18, 2020, CMS released recommendations intended to conserve personal protective equipment, beds and ventilators and limit the exposure of patients and staff to COVID-19. CMS recommended that all non-essential dental exams and procedures be postponed until further notice. CMS also recommended postponing or canceling non-essential adult elective surgery and medical and surgical procedures, and making case-by-case evaluations on whether a planned surgery should proceed. CMS suggested considering a number of factors, such as the patient’s health and age and the urgency of the procedure.
- On March 19, 2020, the ASCA released new guidance to ASCs with respect to what might constitute a “necessary surgery” during the COVID-19 pandemic. The ASCA guidance states that “a surgery may be deemed urgent and necessary if the treating physician decides that a months-long delay would increase the likelihood of significantly worse morbidity or prognosis for the patient,” and provides examples of cases that might still need to proceed with surgery during the COVID-19 pandemic.
- On March 25, 2020, the ASCA released “COVID-19: Elective Case Triage Guidelines for Surgical Care,” to assist in surgical decision-making in curtailing cases. This guidance document by ASCA provides information from the most current best evidence available in the following areas: Cancer surgery, Breast Cancer Surgery, Colorectal Cancer Surgery, Thoracic Cancer Surgery, Emergency General Surgery, Gynecology, Metabolic-Bariatric Surgery, Neurosurgery, Orthopedics, Pediatric Surgery, Urology, and Vascular Surgery.