Updated guidance on elective surgeries in Illinois

Submitted by the Illinois Department of Public Health as of 4.27.2020

Current Status
During the COVID-10 pandemic, surgeries and procedures (collectively referred to as “procedures”) for life-threatening conditions or those with a potential to cause permanent disability have been and continue to be allowed.

Due to the COVID-19 pandemic, hospitals and Ambulatory Surgical Treatment Centers (ASTCs) have deferred nonessential procedures to conserve resources for the care of COVID-19 patients. Some procedures that could reasonably be delayed for a time have now been postponed to the extent that potential harm could result from further delay. It is important to be flexible and allow facilities to provide care for patients needing non-emergent, non-COVID-19 healthcare.1

New Guidance
Beginning on May 11, 2020, hospitals and ASTCs may begin to perform procedures, provided that specific criteria have been met.

A. Outpatient Procedures. For purposes of this policy guidance, an elective outpatient procedure is defined as an elective procedure in which the likely and expected course for the patient undergoing the procedure is that the patient will enter and leave the facility on the same day that the procedure is to be performed. Such procedures may be performed at ASTCs or at hospitals. Clinical decision-making on whether a case is suitable for outpatient procedure should take into account a classification such as the Elective Surgery Acuity Scale (ESAS).2 For a facility to perform outpatient procedures, all criteria listed in Section (D) below must be satisfied.

B. Inpatient Procedures. For purposes of this policy guidance, an elective inpatient procedure is defined as an elective procedure in which the patient being considered for that procedure is likely to remain in the hospital for more than 23 hours, starting from the time of registration and ending at the time of departure. For a hospital to perform inpatient procedures, all criteria listed in both Section (C) and Section (D) below must be satisfied.

C. Regional Requirements for Elective Inpatient Procedures. Elective inpatient procedures should be informed by surveillance of epidemiologic trends, regional hospital utilization, and the hospital’s own capacity. Experience during the pandemic in early 2020 has shown that a regional health system becomes seriously stressed when regional bed or ICU availability drops below 20%. Within a particular hospital, if all three of the following resource conditions are fulfilled, then elective inpatient procedures are permissible at that hospital. If any of the three resource conditions are not fulfilled, then elective procedures are not permissible.
1. Hospital availability of adult medical/surgical beds exceeds 20% of operating capacity for adult medical/surgical beds
2. Hospital availability of ICU beds exceeds 20% of operating capacity for ICU beds
3. Hospital ventilator availability exceeds 20% of total ventilators
These resource requirements are subject to change from time to time, as deemed appropriate by the Director of the Illinois Department of Public Health based on evolving conditions in the COVID-19 pandemic. Elective procedures may be suspended again as determined by the Director of the Illinois Department of Public Health in the event of the following circumstances:
a) rapid resurgence or a second wave of COVID-19
b) decrease in statewide hospital COVID-19 testing levels

D. Facility requirements for Elective Outpatient and Inpatient Procedures. Elective inpatient and outpatient procedures at a facility are permissible if the facility fulfills all of the following conditions:
1. Case setting and prioritization. Each facility should convene and charge a Surgical Review Committee (SRC), composed of surgery, anesthesiology, and nursing personnel, to provide defined, transparent, and responsive oversight of the prioritization of elective inpatient cases. This committee can lead the development and implementation of guidelines that are fair, transparent, and equitable for the hospital or system in consideration of rapidly evolving local and regional issues. The SRC should rely heavily on elective case triage guidelines for surgical care that have been developed by professional societies. 2,3,4,5 The SRC should review regularly a list of previously postponed and canceled cases, prioritizing based on clinical considerations and taking into account the resources and staff necessary for each procedure.4
2. Preoperative Testing for COVID-19. Facilities must test each patient within 72 hours of a scheduled procedure with a preoperative COVID-19 RT-PCR test and ensure COVID-19 negative status. Patients must self-quarantine until the day of surgery after being tested. A temperature check must also be completed on the day of arrival at the facility with results of less than 100.4 degrees prior to proceeding with an elective procedure. When clinically acceptable, providers should consider using telemedicine for preoperative visits. In such cases, face-to-face components of the exam can happen after the result of the preoperative COVID-19 test result is known to be negative.
3. Protective equipment. Facilities may resume procedures only if there is adequate personal protective equipment with respect to the number and type of procedures that will be performed, and enough to ensure adequate supply if COVID-19 activity increases in the community within the next 14 days.
4. Infection control. Facility cleaning policies in all areas along the continuum of operative care must follow established infection control procedures. When possible, facilities should establish non-COVID care zones for screening, temperature checks, and preoperative waiting areas. Facilities should also minimize time in waiting areas, space chairs at least 6 feet apart, and maintain low patient volumes. Visitors should generally be prohibited; if they are necessary for an aspect of patient care or as a support for a patient with a disability, they should be pre-screened in the same way as patients (as described above, Section D.2). Facilities must have the ability to routinely screen all staff and others who will work in the facility (physicians, nurses, housekeeping, delivery and other people who would enter the patient area) with COVID-19 RT-PCR testing.
5. Support services. Other areas of the facility that support perioperative services must be ready to commence operations with uniformly heightened infection control practices, including sterile processing, the clinical laboratory, and diagnostic imaging.

E. Pediatric Procedures. Elective procedures for pediatric patients, whether outpatient or inpatient, are not subject to the requirements in Section (C) but are subject to the requirements in Section (D).
References:
1. Centers for Medicare & Medicaid Services (CMS), Opening Up America Again: Recommendations – Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I, March 19, 2020, https://www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services.pdf.
2. American College of Surgeons, COVID-19: Elective Case Triage Guidelines for Surgical Care, March 24, 2020, https://www.facs.org/covid-19/clinical-guidance/elective-case.
3. American College of Surgeons, COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures, March 17, 2020, https://www.facs.org/covid-19/clinical-guidance/triage.
4. Prachand, V. N., Milner, R., Angelos, P., Posner, M. C., Fung, J. J., Agrawal, N., Jeevanandam, V., & Matthews, J. B. (2020). Medically-Necessary, Time-Sensitive Procedures: A Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic. Journal of the American College of Surgeons, S1072-7515(20)30317-3. Advance online publication. https://doi.org/10.1016/j.jamcollsurg.2020.04.011
5. American College of Gastroenterology, American Gastroenterological Association, American Association for the Study of Liver Diseases and the American Society for Gastrointestinal Endoscopy. Gastroenterology professional society guidance on endoscopic procedures during the COVID-19 pandemic. March 31, 2020. https://webfiles.gi.org/links/media/Joint_GI_Society_Guidance_on_Endoscopic_Procedures_During_COVID19_FINAL_3312020.pdf

Questions about COVID‐19?
Call 1‐800‐889‐3931 or email dph.sick@illinois.gov
Illinois Department of Public Health ‐ www.dph.illinois.gov
Printed by Authority of the State of Illinois 4/24/20 IOCI 20-673