Clinical Decisions article documents three approaches to manage elective surgery during COVID-19

Reviewed by Emily Henderson, B.Sc.Nov 3 2020

Tanira B.D. Ferreira, M.D., FCCP, chief medical officer of University of Miami Hospital and Clinics, was one of three authors featured in the New England Journal of Medicine for her expertise in how to manage elective surgeries during COVID-19 surges.

Elective procedures are low- and intermediate-acuity procedures than can be safely delayed without substantial patient risk.

The Clinical Decisions article published Oct. 29 documents three approaches to managing elective surgery given the same scenario. In the mock scenario, a hospital's census was higher than 90% of capacity, with almost all intensive care unit beds occupied, more than half by patients with COVID-19.

One of the authors made a case for deferring elective surgical procedures, and another author presented a case for continuing all elective procedures. Dr. Ferreira shared the University of Miami Health System's planned approach, which fell in the middle of the other two. It was to proceed with scheduled elective surgical procedures but defer new cases when needed if bed availability was limited.

The scenario in the article was very similar to what we experienced here in Miami in June and July. It gave us the opportunity to share the extraordinary work at UHealth Tower, when we were able throughout the second spike of this pandemic to run full, almost normal hospital operations and at the same time manage the COVID-19 surge. In essence, we created a way in our surge plan for the hospital to manage COVID-19 and non-COVID-19 patients safely and effectively within the same institution."

Dr. Ferreira, Associate Professor of Clinical Medicine, Miller School of Medicine

UHealth's comprehensive approach to managing elective procedures during pandemic surges addresses patients' needs and safety, as well as the financial stability of the hospital.

"Importantly, we developed a model that allows us to locally predict what the expected census would be for our organization within 7 to 14 days in advance. So, we can plan for the increased beds we will need for COVID-19 patients, while safely caring for non-COVID-19 patients," Dr. Ferreira said.

"We now have a projection of a potential third spike by the third week of November. As a result, we are in the process of executing our surge plan so we can implement it when needed."

The University of Miami Health System had already developed its predictive model in May, when Florida Governor Ron DeSantis lifted the state's restrictions on elective procedures. The UHealth Tower model involves implementing vertical isolation. For instance, a COVID-19 positive patient who comes into the emergency department is immediately isolated to a special unit.

"The hospital has 13 floors. We converted the highest penthouse floor to COVID-19 negative pressure rooms with ICU capability," Dr. Ferreira said. "When we anticipated the spike back in June and July, we had isolated negative pressure rooms for 150 COVID patients at one point. Now the COVID-19 census is low, and those rooms have been converted back to regular rooms."

A lot goes into preparing for a surge, including staffing the COVID units and having the needed ventilators, medications and personal protective equipment ready to go. It also involves creating a team to safely discharge patients to make more beds available during a surge. Built into the plan is the ability to work in elective procedures with greater urgency or risk if those cases are deferred.

"Our hospital is prepared for the next surge in this pandemic. The comprehensive plan is so well thought out that it caught the attention of one of the most prestigious scientific journals in the U.S.," Dr. Ferreira said. "Having a plan that safely accommodates COVID-19 and non-COVID-19 patients in a single institution during a pandemic surge is no small effort. The entire UHealth Tower mobilized to create it."