As COVID-19 cases and hospitalizations rise, could elective surgeries stop?

As COVID-19 cases and hospitalizations rise in Arizona, some hospitals are pausing elective surgeries or considering pausing them to ensure there’s enough capacity to handle the influx of patients.

Yuma Regional Medical Center last week began scaling back on some elective cases with inpatient stays because of staffing needs.

At Dignity Health, two hospitals are reducing elective surgeries over the next week to "prepare for additional surge capacity and give us additional time to support and increase our staffing," spokeswoman Carmelle Malkovich said in an email.

Banner Health, the state’s largest hospital system, is "making adjustments" this week to its elective surgery decisions based on capacity and staffing at individual hospitals, spokeswoman Becky Armendariz said. Banner is now using traveling nurses to help with staffing and has had more than 200 travel nurses join Banner hospitals in the past week, she said.

Hospitals were allowed to resume elective procedures, which were paused for more than a month, starting May 1, provided they met certain criteria for available personal protective equipment, beds and staffing, according to an executive order from Gov. Doug Ducey in late April.

Arizona is not the only state facing the issue. In Texas on Thursday, Republican Gov. Greg Abbott announced he was stopping elective surgeries in four counties as cases and hospitalizations rise there.

The term "elective" is a bit of a misnomer. In many cases, these procedures are needed for quality-of-life and ongoing treatment for serious diseases, such as cancer. Elective surgeries and procedures are still important, and when elective surgeries were on hold, patients said they were struggling with the delays. The lack of elective procedures also taxed finances for hospitals, some of whom furloughed or laid off workers.

Non-essential or elective surgeries are ones that can be delayed "without undue risk to the current or future health of a patient," according to the governor's order. Doctors are told to use their best judgment in determining whether a surgery is elective. A surgery is not elective if delaying will be life-threatening or cause permanent physical dysfunction, impairment or hospitalization.  

The Arizona Department of Health Services is monitoring hospital capacity, spokeswoman Holly Poynter said in an email. As of Wednesday, 85% of current inpatient beds and 88% of ICU beds were in use for COVID-19 and other patients.

Arizona reported another 3,056 new COVID-19 cases Wednesday and a record 2,453 patients hospitalized as trends continue to worsen statewide with no sign of abating.

Inpatient beds and ventilators in use for suspected and confirmed COVID-19 patients both hit their highest-ever numbers on Wednesday, according to the daily report from the state health department released Thursday morning.

Emergency department visits and ICU beds in use hovered around their highest levels as well, as Arizona deals with one of the worst surges of COVID-19 in the country.

On Wednesday, Arizona State University released updated models of the disease’s progression in the state. The model estimated transmission of the disease has increased 40% since May 11, shortly before the stay-at-home order ended, which could create an "exponential growth curve" going forward.

If the model predictions come to fruition, Arizona may run out of available hospital beds by late June or early July, which would warrant moving into surge capacity.

Available beds differ from hospital to hospital, and it’s possible that some places could fill up more quickly than others, said Joshua LaBaer, executive director of ASU's Biodesign Institute.

"In the next few weeks, it's certainly likely to see that some hospitals are going to start reaching capacity, at least their stated capacity that doesn't necessarily account for surge capacity," LaBaer said. "But then surge capacity is just that: it's not something that you can maintain forever."

LaBaer said he hopes policymakers are looking hard to data right now to assess whether elective surgeries can continue.

What are hospitals doing now?

Most larger hospital systems have not yet paused elective surgeries but are carefully monitoring capacity in case they need to. Others have begun scaling back. 

Yuma Regional Medical Center last week began scaling back elective cases with inpatient stays due to staffing needs. Outpatient surgeries have continued so far. Hospital staff meet daily to review resources and reschedule elective procedures when needed, spokeswoman Machele Headington said in an email.

"We recognized that cancelling any procedure is difficult for patients and families, and for that we sincerely apologize," Headington said. "During a pandemic we are challenged in a way that may require added measures that support the overall safe care of patients."

Yuma County has been one of the hardest-hit counties statewide, with case increases of around 1,500% since the stay-at-home order expired in mid-May, compared to around 350% statewide. 

In the Phoenix area, some hospitals are pausing and reassessing too, while others say they have enough capacity to continue with elective surgeries.

For the next week, Dignity St. Joseph’s Hospital and Medical Center and St. Joseph's Westgate Medical Center will only be performing urgent procedures for the time being. Elective cases that are scheduled will move forward, but no new elective surgeries will be added next week, according to Malkovich, Dignity's spokeswoman.

Armendariz, of Banner, said she did not have specific details on which Banner hospitals could be adjusting surgery processes or criteria.

Banner is recommending people who need or are scheduled for surgery contact their doctor to find out if surgeries will proceed or be postponed, Armendariz said.

"The surgeons are working closely with hospitals’ surgery departments to make those decisions," she said.

HonorHealth hospitals in Phoenix and Scottsdale have sufficient capacity, staffing, beds, ventilators and PPE to continue doing elective surgeries. The hospitals closely monitor COVID-19 patient admissions to make sure all patients can safely get care. If things change, the hospitals could scale down on some elective procedures.

Other sites, such as Chandler Regional and Mercy Gilbert Medical Centers are monitoring elective surgical cases that would result in inpatient admissions on a daily basis to make sure the hospitals maintain enough capacity.

"We are seeing an increase in the overall number of patients currently receiving care at our facilities," Malkovich said. "As of now, we currently have available ICU bed capacity and ventilators. We are closely monitoring our staffing levels and are actively working to provide extra support to help our staff."

Valleywise Health, which runs 17 health facilities across Maricopa County, is currently continuing with elective surgeries but regularly evaluating hospital capacity, according to chief medical officer Michael White.   

At Santa Cruz Valley Regional Hospital near Arizona’s southern border, elective surgeries are continuing as usual, but they have not come back as fast as the hospital expected, according to hospital CEO Kelly Adams. The hospital is watching for PPE levels, she said, so that if surgeries use up more PPE than can be provided, things will be reassessed.  

The hospital is at around 30% of ICU beds filled and 25% of inpatient beds filled.  

How did hospitals restart elective procedures?

Starting April 22, hospitals were allowed to resume elective surgeries if they could demonstrate adequate capacity and preparedness, according to the governor’s executive order. Elective surgeries had been paused on March 19 to give hospitals capacity to prioritize beds and PPE for COVID-19 patients.

Hospitals are required to have more than two weeks’ worth of PPE. They must not exceed 80% of total occupied beds, and they must have adequate staffing. Hospitals need testing plans to test health care workers and each patient prior to their elective surgery. Also necessary is a screening process for staff, patients and visitors as well as enhanced cleaning within the hospital.

Hospitals had to demonstrate to the Arizona Department of Health Services that they met all the above requirements before they could resume elective surgeries. The department has the authority to revoke elective surgery privileges if hospitals do not meet the standards.  

As of Tuesday, the health department had not told any hospitals to pause elective procedures. 

"ADHS continues to work with the various hospitals, hospital systems, and partners to help ensure hospitals are prepared and that care is available to anyone that needs it," spokeswoman Holly Poynter wrote in an email. "While ADHS has not taken any formal action, ADHS is closely monitoring hospital capacity and the ability of each hospital or hospital system to comply with Executive Order 2020-32."

The department has told hospitals that if they resumed elective surgeries but are now experiencing staffing or bed shortages, they must "suspend electives immediately."

"Be judicious and reduce or suspend elective surgeries to ensure adequate bed capacity for both COVID and non-COVID admissions," the health department wrote to hospitals in late March and again in early June.

Reach reporter Rachel Leingang by email at rachel.leingang@gannett.com or by phone at 602-444-8157, or find her on Twitter and Facebook.

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