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Many of you were looking forward to your elective orthopedic surgery this spring. Maybe you were hoping to get your knee or hip replacement done before the summer golf season arrived or maybe before that trip with the grandkids. Then the unexpected happened and life as we’d planned it, halted.
As we begin to phase back into a new normal, most, if not all, hospitals and health care systems are using the Centers for Medicare and Medicaid Services (CMS) tiering system to evaluate the urgency of care that needs to be delivered. The CMS system is designed to help surgeons and clinicians evaluate which types of patients need to be treated and which can be delayed. This applies to non-emergency, elective problems. Meaning, if you were in an accident or otherwise needed emergency care, then you would receive the care that you needed, and no tiering system would need to be applied.
What are the tiers?1
Tier 1 priority includes conditions that are considered non-urgent and can likely be delayed with minimal patient risk. Examples of tier 1 procedures are routine health maintenance, preventative exams/screenings, supervised exercise therapy, and acupuncture.
Tier 2 priority includes conditions that are of intermediate urgency. By not providing treatment to these patients, they could become worse in the long term. These conditions can be delayed, but not indefinitely. It’s also most likely the tier where most of our elective surgeries reside. Other examples of tier 2 procedures are pediatric vaccinations, follow-up visits for existing condition management, and evaluation of non-urgent, non-COVID symptoms.
Tier 3 priority conditions are those of high urgency. These could result in harm to patients if not treated in a timely manner. An example in orthopedic surgery would be non-emergency fracture care because we know that if a fracture is not fixed, patients will likely have a worse outcome. Experiencing COVID-19 symptoms would be considered a tier 3 priority.
If you’re interested in reading further about how these different tiers will begin to roll out, check out the official phasing criteria from the White House by clicking here.
The other important thing to remember is that these guidelines are meant to help provide guidance to providers, surgeons, hospitals, and health systems. However, it also recognizes that it’s important to make decisions based on local factors. This could include factors like the number of COVID-19 cases, both positive and projected, in your community, as well as the availability of personal protective equipment (PPE) in the medical facility, testing ability, and so forth.
Now that many states are starting to move into various phases of their COVID-19 plans, many surgeons and health systems are figuring out how to start performing many of the elective cases that were postponed during the earlier phases. This will be influenced by many of the factors previously mentioned. Hospital systems with an abundance of PPE and low instance of COVID-19 may start to perform elective cases more quickly than their counterparts. Many hospitals require that patients undergo testing prior to having their elective surgery, so access to tests and the ability to test individuals may also influence when more elective surgeries will start to be done in your community.
As surgeons begin performing more elective surgeries it’s important to remember that they may have dozens or even hundreds of cases to re-schedule, depending on how long their hospital limited elective surgeries. It’s also important to understand that hospital and surgeon capacity to perform cases will not immediately return to 100% based on available space and staff. Many hospitals are designating certain operating rooms solely for the use of COVID-19 patients. This helps limit the exposure of other patients and staff to those spaces, and allows for a full decontamination of the operating room after these surgeries. In some cases, staff may not even be available due to illness, or they may be called to help in another part of the health care system.
Each surgeon and medical facility may employ different strategies as they begin to perform more elective cases. Some may focus on the Tier 3 cases. Some may simply start doing the patients that have been postponed the longest. Others may focus on cases that will use fewer hospital resources, like outpatient or observation surgeries rather than surgeries that are likely to result in hospitalization. They will also likely focus on specific patient factors and try to limit exposing those at high risk for contracting COVID-19. A combination of all these factors will likely be the case in most practices.
Another thing to remember is that your surgery will likely look different than it would have last year. You may have limited, or no visitors allowed during your recovery in the hospital. Your family and friends may be asked to wait in their cars instead of in a waiting room. Maintaining distance and wearing masks will be a reality for you and your loved ones in the hospitals as well as in clinics. Your surgeon may also offer you remote care visits via video or telephone before or after surgery to help minimize contact between patients.
Likely, all of these things will factor into when your elective surgery will be re-scheduled. Please know, the hospitals and surgeons know that while your surgery may be elective it’s still important. While it might not be an emergency, it’s having a very large impact on your life and getting it done will hopefully be a life changing event. Stay in touch with your surgeon’s office about how they’re caring for patients. If you have a significant change in your condition let them know immediately.