Rolling Back Elective Surgeries in Texas

COVID-19’s surge in Texas prompted Texas Governor Greg Abbott to pause the reopening process and resume an elective surgery ban in an attempt to reserve hospital space for those suffering from COVID-19.

Texas’s elective surgery ban targets and initially affected only four counties, which, it turns out, are also the four most populous cities in the state, Houston, San Antonio, Dallas, and Austin. It does not yet include neighboring counties that encompass suburban or neighboring cities, such as Fort Worth. The ban was expanded on June 30 to include four additional counties in South Texas for the cities of Corpus Christi, Brownsville, McAllen, and Laredo.

OTW spoke to a couple of surgeons from the Texas Back Institute (TBI), which has an affected facility in the city of Dallas, as well as other locations in the Dallas area to get a sense for how the ban is affecting their operations.

Jack Zigler, M.D. talked about the earlier ban that was initially lifted in May, indicating that TBI still had a backlog of cases. During the first ban some patients showed progression and more severe symptoms, such as bowel or bladder control issues, and were brought in for emergency surgery. TBI made an effort to reduce the risk to patients and staff by implementing many social distancing and personal protective equipment requirements. Telemedicine was used extensively to continually monitor patients whose procedures had been postponed. The latest ban affects only the Dallas location, and TBI surgeons with cases scheduled in Dallas hospitals are working to reschedule procedures in Plano and Frisco, according to Zigler.

Zigler is hopeful that “more appropriate restraint by the public, and better adherence to social distancing and masking, along with less unnecessary gathering, that there will be a decrease in hospitalizations and an increase in reserve capacity,” will lead a reduction in new cases and lifting of the ban. Hopefully, the announcements made by Governor Abbott will bring attention to the rising number of cases. Over the past few weeks several states have issued mandatory mask orders to help bring attention to the importance of wearing a mask to reduce the spread of COVID-19. The issue has become political with pushback in many areas.

Isador (Izzy) Lieberman, M.D., another surgeon at TBI, spoke about the handling of this and the previous ban on elective surgery and the policies the surgical group and area hospitals have been practicing despite the roll-back of regulations in the state over the previous weeks.

According to Lieberman, TBI has required all patients and staff to wear personal protective equipment and practice social distancing whenever possible. Additionally, Dallas-area hospitals, such as Medical City Dallas, have had strict regulations in place since cases appeared in the area months ago. For example, patients coming for non-emergency procedures have been required to undergo COVID-19 testing two days prior to the schedule surgery, and to remain quarantined in the interim.

Emergency cases have been rerouted to the Plano location to reduce the chances of COVID-19 spread in the Dallas Hospital. Lieberman reported that Medical City Dallas has not experienced any cases of COVID-19 spread within the hospital. He believes that continued use of telemedicine, and protective equipment and social distancing will allow TBI to safely continue elective procedures where permitted. Lieberman also pointed out that many patients have voluntarily postponed surgery, because many don’t feel it is worth the risk of potential exposure. Additionally, he added, patients are not leaving their homes as frequently and finding that they can get along for a while without surgery.

Lieberman pointed out that, currently, the ban has almost no teeth behind it. Violations of the ban are subject to a paltry $1,000 fine, and the determination of the urgency of procedures is at the discretion of the physician, so it is unlikely a surgeon could be stopped if he or she were determined to perform elective procedures.

In South Florida, primarily near Miami, hospitals have voluntarily cancelled some elective surgeries in order to reserve hospital space and resources for COVID-19 patients. Jackson Health System said it would cancel surgeries starting July 6 due to the surging number of COVID-19 hospitalizations which have doubled over the last two weeks.

Despite the use of an estimated 83% of hospital capacity in Arizona nearly three weeks ago, the state has not issued a ban on elective surgeries. As part of the state’s phased reopening passing the 80% capacity threshold should have triggered the cancellation of elective surgeries. However, Governor Doug Ducey has not imposed any additional restrictions since the state’s reopening in May. Yuma Regional Medical Center, Dignity Health in Phoenix, and others have voluntarily reduced or cancelled elective procedures that they are performing. Health systems in Arizona project that capacity will run out in July

So far, Texas is the only state to officially ban elective procedures anywhere. Hospital systems in areas with increasing cases of COVID-19 must balance doing their part to keep patients safe and performing enough procedures to pay the bills. Not only are elective procedures down, but people are (wisely) avoiding the emergency room for non-COVID-19 issues, further impacting hospital income. Many hospitals are struggling to stay open as they lose millions of dollars each day; analysts expect many to consolidate, go bankrupt and/or close. What used to be a “free” call to your doctor to check on test results is now often being scheduled as a billable telemedicine appointment. While the use of telemedicine has helped hospitals financially, it likely won’t turn the tide.