On April 23, Oregon’s Governor Kate Brown announced that healthcare providers in Oregon could resume non-urgent medical procedures beginning May 1. Washington’s Governor Jay Inslee followed with a similar announcement on April 29. Each leader introduced guidelines setting out the requirements that must be satisfied for non-emergent services to resume. Those guidelines are summarized below. 

OREGON

Oregon introduced a bifurcated approach to non-emergent services, one plan for hospitals and ambulatory surgical centers (ASCs), the other for medical and dental offices. The priorities for resuming services were similar, with the differences noted below:  

Hospital/ASC Priorities

• Minimize the risk of SARS-CoV-2 (the coronavirus that causes COVID-19) transmission to patients, healthcare workers and others;
• Avoid further delays in healthcare for Oregonians;
• Maintain adequate hospital capacity in case of an increase in COVID-19 cases;
• Minimize transfers to skilled nursing facilities and other long-term care facilities due to the vulnerability of these congregate care settings; and
• Reduce financial impacts to Oregon’s health system.

Medical/Dental Office Priorities

All of the above, plus:

• Minimize health emergencies presenting at emergency departments; and
• Support the healthcare workforce in safely resuming activities.

Similarly, the guidelines set out criteria that must be satisfied to address the above priorities, again categorizing the criteria separately for hospitals/ASCs and medical/dental offices. 

Hospital/ASC Criteria

In order to address these priorities, the following steps and specific criteria must be met in order to resume and maintain non-emergent and elective procedures:

• Prior to resuming non-emergent and elective procedures, the following criteria must be met:
  • Capacity at the hospital (i.e., bed capacity and healthcare workforce) can accommodate an increase in both COVID-19 hospitalizations in addition to increased post-procedure hospitalizations and other ongoing needs for hospital level of care.
    • Hospital bed availability in the region must remain at or above 20% in order to accommodate the potential for increased COVID-19 hospitalizations.
    • Facilities must be able to treat all patients requiring hospitalization without resorting to crisis standards of care.
  • Facility has adequate PPE supplies on hand.
    • Facility shall maintain a 30-day supply of PPE on hand; for small facilities, a 2-week supply of PPE on hand and an open supply chain is adequate.
    • Facility can sustain recommended PPE use for its healthcare workforce without the need for emergency PPE-conserving measures. If a facility proposes to extend the use of or reuse PPE, it must follow CDC guidance.
      • Hospitals must continue to report all PPE supplies daily through the Oregon Health Authority’s Hospital Capacity web system (HOSCAP).
  • Facility has access to adequate testing capacity.
    • Facility has access to COVID-19 testing when needed that ensures results within 2 days. For small facilities, access to COVID-19 testing when needed, that ensures results within 4 days.
    • When adequate testing capability is established, consider screening patients by laboratory testing before proceeding with a non-emergent or elective procedure.
  • Facility is following strict infection control and visitation policies.
  • Necessary resources for peri-operative care are available.
    • This includes but is not limited to access to pre- and post-operative visits with necessary providers; laboratory, radiology and pathology services; and other necessary ancillary services.
• Once non-emergent and elective procedures resume, they must start slowly, and criteria should be reassessed biweekly.
  • To start, facilities must limit the volume of non-emergent and elective procedures to a maximum of 50% pre-COVID-19 procedure volume.
  • In order to maintain or expand this volume, facilities must continue to meet all items in 1 (a-e).
  • Facility must maintain a plan to reduce or stop non-emergent and elective procedures should a surge/resurgence of COVID-19 cases occur in their region or in the case that criteria 1 (a-e) cannot be met.
  • Procedures must be prioritized based on whether their continued delay will have an adverse medical outcome.
    • A medical committee, or the medical director, of a facility shall review and prioritize cases based upon indication and urgency.
    • Facilities must strongly consider the balance of risks vs. benefits for patients in higher-risk groups such as those over age 60 and those with compromised immune systems or lung and heart function
    • Facilities should consider ongoing postponement of non-emergency and elective procedures that are expected to require the following resources:
      •  Transfusion
      • Pharmaceuticals in short supply
      • ICU admission
      • Transfer to skilled nursing facility or inpatient rehab

Approach and Criteria for Medical and Dental Offices

To address each of these priorities, the following steps and specific criteria must be met in order to resume and maintain non-emergency and elective procedures in office settings (i.e., medical and dental offices) requiring PPE:

• Prior to resuming non-emergency and elective procedures in medical or dental offices, the following criteria must be met:
  • The office must have adequate PPE supplies on hand.
    • The medical or dental office can sustain recommended PPE use for its workforce for two weeks without the need for emergency PPE-conserving measures.
    • If a facility proposes to extend the use of or reuse PPE, it must follow CDC guidance.
  • Medical or dental office is following strict infection control policies as recommended by CDC.
• Once non-emergency and elective procedures resume, start slowly and reassess every two weeks.
  • Decrease caseload volume to maximize social distancing.
    • Medical and dental offices should implement social distancing measures within waiting rooms and other areas of the office.
    • Medical and dental offices should use physical barriers within patient care areas when possible.
  • In order to maintain or expand this volume, office must continue to meet all items in 1 (a-b).
  • Medical or dental office must maintain a plan to reduce or stop non-emergency and elective procedures should a surge/resurgence of COVID-19 cases occur in their region.
  • Prioritize procedures based on whether their continued delay will have an adverse health outcome.
    • Non-emergent and elective procedures should be prioritized based on indication and urgency.
  • Strongly consider the balance of risks vs. benefits for patients in higher-risk groups such as those over age 60 and those with compromised immune systems or lung and heart function.
  • Medical and dental offices should utilize enhanced risk screening of patients prior to delivering care.
    • Pre-screen patients via tele-medicine or tele-dentistry when applicable.
    • Screen all patients for COVID-19 risk factors and symptoms, including temperature checks.
      • Patients with COVID-19 symptoms should not undergo non-emergent or elective procedures.
      • When adequate testing capability is established, consider screening patients by laboratory testing before proceeding with a non-emergent or elective procedure.

The Governor’s Office, in consultation with the Oregon Health Authority, will determine the necessary tools to monitor that these criteria are being met and when different or additional criteria should be considered.

WASHINGTON

Governor Inslee: Clinician Judgment Guides Provision of Medical Services

On April 29, 2020, Gov. Jay Inslee issued much-needed clarification of his Proclamation 20-24, which imposed restrictions on non-urgent medical procedures. The clarification, entitled “Interpretive Statement Related to Proclamation by the Governor 20-24, Restrictions on Non Urgent Medical Procedures,” sets out guidance for the operation of outpatient medical clinics and the performance of non-emergent or non-urgent medical procedures during the pendency of Inslee’s stay-at-home order.

The Interpretive Statement makes three important points: 

1. All services considered “urgent” or “emergent” are currently permitted;
2. Outpatient clinic visits, whether in hospital-based or other outpatient settings (g., medical practices), are permitted, subject to clinicians’ judgment in weighing the benefits versus the risks of providing in-person services (telehealth is encouraged); and
3. Performance of non-urgent or non-emergent procedures is permitted, provided that clinicians use their clinical judgment to determine the relative harm to patients of treatment versus deferment of treatment, in terms of the risk of either the patient or the provider contracting COVID-19.

Notably, “harm” is not defined in the Interpretive Statement; rather, assessment of harm is left up to individual clinicians. The assessment of potential harm should consider whether a patient’s illness or injury is:

• causing significant pain;
• causing significant dysfunction in daily life or work; or
• progressing, or at risk to progress.

Additionally, clinicians should consider the risk of harm that could arise as a result of undergoing the procedure during the COVID-19 pandemic.

Criteria for Performing Non-emergent Procedures

According to the Interpretive Statement:

The decision to perform any surgery or procedure in hospitals, ambulatory surgical facilities, dental, orthodontic, and endodontic offices, including examples of those that could be delayed in the Proclamation, should be weighed against the following criteria when considering potential harm to a patient’s health and well-being as described above:

• Expected advancement of disease process
• Possibility that delay results in more complex future surgery or treatment
• Increased loss of function
• Continuing or worsening of significant or severe pain
• Deterioration of the patient’s condition or overall health
• Delay would be expected to result in a less-positive ultimate medical or surgical outcome
• Leaving a condition untreated could render the patient more vulnerable to COVID-19 contraction, or resultant disease morbidity and/or mortality
• Non-surgical alternatives are not available or appropriate per current standards of care
• Patient’s co-morbidities or risk factors for morbidity or mortality, if infected with COVID-19 after procedure is performed

Furthermore, diagnostic imaging, diagnostic procedures or testing should continue in all settings if disease is suspected, based on clinical judgement that uses the same definition of harm and criteria as listed above.

Prerequisites to Performing Healthcare Services, Procedures and Surgeries

Prior to performing healthcare services, procedures and surgeries, providers must (i) ensure that they can meet applicable infection prevention and control standards, (ii) maintain appropriate personal protective equipment supplies, and (iii) follow Department of Health-issued guidance on use of PPE. Specifically, the following are required: 

• Facilities must provide health care workers (direct patient care and affected ancillary staff) with appropriately sized and sufficient quantities of PPE to perform essential job functions.
• Facilities must be aligned with Washington State Department of Health’s PPE Usage Guidelines – PPE Conservation Strategies (Yellow), which says personal protective equipment is discarded and replaced when it is soiled, damaged, or hard to breathe through.
• Facilities must follow the Washington State Department of Health’s Guidance on Extended and Re-use of PPE by Healthcare Personnel (HCP).
• Facilities must have on-hand and in the facility 7 days of appropriate PPE.
• Facilities must report accurate counts of PPE available and in the facility daily, as well as PPE on order, to the WA Health system.
• Facilities must report following required DOH guidelines for PPE use to the WA Health system.
• Health care workers have access to COVID-19 testing and to timely notification (within eight (8) hours of awareness) of exposure to COVID-19.
• Facilities must report on COVID-19 positive health care workers by facility and profession/position to the WA Health system.

Further guidance is expected soon from the Governor’s office, and it is likely that additional information will be forthcoming from the Department of Health. We will monitor further developments and will issue further alerts as needed.