As Covid-19 cases surge, some hospitals are once again delaying elective surgeries. But based on their experiences postponing surgeries last year, they're now being more selective about what procedures they're deeming "elective," Claudia López Lloreda reports for STAT News.

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The dangers of delaying "elective" surgeries

The term "elective" is used to describe a surgery that doesn't need to be done immediately "to maintain life or limb," Brian Cole, chair of surgery at Rush Oak Park Hospital, said. "But it's a very nebulous term to call something elective."

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At the start of the pandemic last year, virtually all scheduled operations were deemed "elective." But studies of the affected patients reveal that those delays may have led to significant health consequences.

For example, one study from Mount Sinai Hospital found that, following delays in transcatheter aortic valve replacement surgeries, 10% of affected patients experienced a cardiac event within the first month, and 35% experienced such an event within the next three months.

Another study from the University of Bern in Switzerland similarly found that delaying aortic valve replacements increased patients' risk of experiencing hospitalization and worsening heart failure.

And a report from the British Heart Foundation estimated that there were 5,800 excess deaths from heart and circulatory conditions in the United Kingdom in 2020 due to delays in cardiology care related to Covid-19.

Some providers also say that, as a result of care disruptions over the last year, some patients now have more serious needs. For instance, surgeons at Covenant High Plains Surgery Center in Texas noted about a 10% increase in the severity of conditions among patients entering the hospital. "Patients who had delayed their procedures may have had more complex procedures or may have come in sicker as a result," Alfonso del Granado, administrator and CEO of the center, said.

How some hospitals are choosing which surgeries to delay

Now, as Covid-19 cases surge in many states, hospitals are being forced to decide once again which surgeries they will delay. In Texas, for instance, Gov. Greg Abbott (R) asked providers to delay some elective surgeries to free up hospital beds.

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"It's just agonizing to have to go through this with our patients again," said Avital O'Glasser, medical director of the preoperative medicine clinic at Oregon Health and Science University Hospital. She added that, while her hospital has yet to delay any surgeries, "it's mentally and emotionally tough to be staring down this possibility again."

Some hospitals are being very deliberate about which procedures they deem to be "elective." At Vanderbilt University Medical Center, for example, doctors evaluate cases every morning to determine which procedures can be rescheduled based on the specifics of each case.

In Oklahoma, Tulsa Bone and Joint Associates has been delaying some—but not all—elective orthopedic procedures for lack of hospital beds. "[T]otal joint replacement, we could delay that," Wesley Stotler, an orthopedic surgeon, said. "But a fracture has a healing time and could heal in the wrong position if we do not fix it appropriately and in a timely fashion. Those are more urgent cases."

In other instances, the coronavirus more directly forces delays in procedures. "Just the other day, I had to cancel an elective surgery because the patient walked into the building and she was Covid-positive and sick," David L. Holden, an orthopedic surgeon and president-elect of the Oklahoma State Medical Association, said. "So we had to send her home."

Some providers argue that even patients whose conditions may not seem critical could still face cascading consequences if their procedures are delayed.

Seth Trueger, an emergency physician at Northwestern Medicine, gave the example of a patient with a scheduled knee surgery. He said that if that procedure is delayed, the patient could suffer chronic pain that could prevent them from exercising, which could in turn lead to other conditions.

"There are clearly conditions that, if neglected and go without surgery, will end up in a different place later on if that surgery does not occur," Cole said.

To avoid canceling surgeries, hospitals that are part of larger systems could consider transferring patients to affiliated hospitals in areas where Covid-19 case counts are lower, Lloreda reports. However, that strategy won't work in places like Florida or Texas, where cases are surging throughout the state.

Ultimately, experts told Lloreda that the problem won't be resolved until Covid-19 case counts decline. Then, hospitals will be able to reliably schedule elective surgeries again. (Lloreda, STAT News, 8/13; Keefover, KTUL, 8/13; Svitek, The Texas Tribune,  8/9)