Amid COVID-19, What Does “Elective” Mean?

As Sarac et al. note in the latest JBJS fast-tracked article, the phrase “elective procedure” is ambiguous, even though it is supposed to identify procedures that are being postponed to help hospitals cope with the COVID-19 pandemic. Guidelines from the Centers for Disease Control and Prevention (CDC) say that operations for “most cancers” and “highly symptomatic patients” should continue, but that leaves much of the ambiguity unresolved. What constitutes an elective procedure in orthopaedics at this unusual time remains unclear.

To help clarify the situation, the authors summarize guidance issued by states and describe the guidelines currently in use for orthopaedic surgery at their institution, The Ohio State University College of Medicine.

Here are the state-related data collected by Sarac et al., as of March 24, 2020:

  • 30 states have published guidance regarding discontinuation of elective procedures; 16 of those states provide a definition of “elective” or offer guidance for determining which procedures should continue to be performed.
  • 5 states provide guidelines specifically mentioning orthopaedic surgery; of those, 4 states explicitly permit trauma-related procedures, and 4 states recommend against performing arthroplasty.
  • 10 states provide guidelines permitting the continuation of oncological procedures.

In the Buckeye State, the Ohio Hospital Association asked each hospital and surgery center to cancel procedures that do not meet any of the following criteria:

  • Threat to a patient’s life if procedure is not performed
  • Threat of permanent dysfunction of an extremity or organ system
  • Risk of cancer metastasis or progression of staging
  • Risk of rapid worsening to severe symptoms

Mindful of those criteria, individual surgical and procedural division directors at the authors’ university developed a list of specific procedures that should continue to be performed. Respective department chairs approved the lists, which were then sent to the hospital chief clinical officer for signoff.

The authors tabulate the orthopaedic procedures that continue to be performed at their institution as of March 25, 2020, but they are quick to add that even this list is not without ambiguity. For example, surgery should continue on “select closed fractures that if left untreated for >30 days may lead to loss of function or permanent disability,” but that requires surgeons to judge, in these uncertain and fluid times, which fractures necessitate fixation in the short term.

Sarac et al. emphasize that such lists, however specific they are today, are likely to change as demands on hospitals shift. They suggest that as the pandemic evolves, a further classification of procedures into 2 time-based categories might be helpful: (1) those that need to be performed within 2 weeks and (2) those that need to be performed within 4 weeks. Sarac et al. also remind orthopaedic surgeons to provide patients waiting for surgery that has been postponed with information regarding safe and effective methods of managing their pain.

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