key: cord-0984778-ossugbdq authors: Sarac, Benjamin A.; Schoenbrunner, Anna R.; Wilson, Stelios C.; Chiu, Ernest S.; Janis, Jeffrey E. title: Coronavirus Disease 2019 State Guidelines on Elective Surgery: Considerations for Plastic and Reconstructive Surgeons date: 2020-05-11 journal: Plast Reconstr Surg Glob Open DOI: 10.1097/gox.0000000000002904 sha: e358f9154440dcf1581328353813d3232652a4d7 doc_id: 984778 cord_uid: ossugbdq Vague recommendations regarding elective surgery have been proposed by national organizations in an attempt to conserve personal protective equipment and to protect healthcare workers during the coronavirus disease 2019 pandemic. In response, some states have attempted to provide more clear guidance. METHODS: An internet search was performed to identify and analyze what guidance each state published through government websites through April 10, 2020. RESULTS: Thirty-five states and the District of Columbia published guidance in the form of either a recommendation or a mandate. Procedures relating to cosmetics and malignancy were found to be mentioned in 4 and 12 states, respectively, but ultimately lacked case-specific information. CONCLUSIONS: Current government and state recommendations do not provide clear guidance on how plastic and reconstructive surgeons should approach elective surgeries. Ultimately, it is the responsibility of all plastic and reconstructive surgeons to operate under appropriate law while individualizing their practices to best suit the needs of their patients while being mindful of resource limitations and exposure risks. The Coronavirus Disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has influenced national and local healthcare policy and has abruptly changed medical practices around the world. The United States has lacked clear guidance from national societies on how surgical and procedure-oriented professions should temporarily alter their practices. On March 13 and 15, 2020, the American College of Surgeons 1 and Centers for Medicare and Medicaid Services (CMS), 2 respectively, released recommendations on how to approach elective/nonurgent surgery. Recommendations, however, are not guidelines and, thus, neither mandatory, nor enforceable. In light of CMS guidelines and an overall effort to decrease unnecessary utilization of personal protective equipment (PPE), many states have published more official guidance on how to address elective surgeries and procedures during the pandemic. The effect this will have on plastic and reconstructive surgery as a specialty will be variable and unpredictable. The authors seek to communicate the landscape of the most current guidance published by each state and provide discussion on the impacts to the field of plastic and reconstructive surgery. To identify recommendations, the Ambulatory Surgery Center Association State Guidance on Elective Surgeries webpage was referenced in addition to an independent internet search. 3 Thirty-five states and the District of Columbia (71%) published guidance for healthcare providers that came in the form of either a mandate or a recommendation. Characteristics of the date of announcement, implementation, and end date are shown in Table 1 . Of the 36 with published guidance, 18 contain specific guidance. [5] [6] [7] [8] 10, 14, 16, [18] [19] [20] [21] 24, 25, 28, 30, 31, 33, 38 Table 2 summarizes the specific guidance because it relates to plastic and reconstructive surgery. As a specialty that performs a large number of elective and outpatient surgeries, the long-term consequences of the COVID-19 pandemic on plastic surgery are unknown. With 71% of states currently recommending limitations on elective procedures, it is postulated that there will be a negative financial impact for both private and academic surgeons. But the state guidelines do not just impact plastic surgery; plastic surgeons play a role in the larger picture and can ultimately contribute positively or negatively to overall disease burden and PPE. To briefly assess the impact of the temporal trend compared with cases, the states of the authors' institutions can be analyzed. The 2 states under evaluation are Ohio and New York, both of which have published guidance during our data collection period. Ohio's guidelines, however, are published 6 days before New York's. 26, 28 At the time of their respective publications, Ohio had 67 confirmed cases (0.57 cases per 100,000 people) 40 and New York had 12,339 confirmed cases (63 cases per 100,000 people). 41 If New York had issued guidance on the same day as Ohio, it would have occurred when the state was at roughly 5 cases per 100,000 persons. As it currently stands at the time of writing on April 10, 2020, Ohio has controlled the disease better than New York, at 50 and 486 cases per 100,000 persons, respectively. Although guidelines on elective surgery are certainly not the only factor influencing disease transmission, one can speculate the impact it has on disease burden as a single piece of a bigger objective toward overall eradication of the virus. Further, early data from China suggest a relatively high patient mortality rate of 20.5% when performing elective surgery during the asymptomatic incubation period of COVID-19. 42 The other side of the double-edged sword, however, is how the guidelines will affect plastic and reconstructive surgeons. Those who have built practices in areas such as cancer reconstruction will less likely be affected than the surgeons in cosmetic-only service. Accordingly, 4 of the 18 states that gave specific guidance specifically mentioned cosmetic procedures, while leaving other areas, such as reconstructive surgery, without mention. 10,20,24,38 Although the current absence of elective procedures can be discouraging, Wang et al 43 in China have shown that volume will increase appropriately following adequate control of the disease, and as such, surgeons should be prepared to resume normal workload. Furthermore, the response to the COVID-19 pandemic is unlike others encountered in world history, as Rohrich et al 44 explain in their recent article. In their article, they discuss that in case of other pandemics, such as the Spanish Flu, governing agencies did not provide public health mandates such as social distancing, and surely there were no elective surgery guidelines. Agencies such as CMS have adapted by providing detailed tiered systems on how to approach surgery during a global health crisis. Tiers range from lower acuity 1a to higher acuity 3b and are given recommendations of postpone, consider postponing, or do not postpone. The approach to cancer, though, is nuanced. "Most cancers" are placed into category 3a, meaning, do not postpone. However, the CMS guidelines do not provide commentary as to which aspects of oncology treatment should be postponed, leaving reconstructive surgeons without clear guidance. 2 Using breast cancer as an example, the number of women who undergo immediate breast reconstruction following breast surgery ranges from 41% to 63%, 45 which necessitates the need for official direction on the approach to reconstructive breast surgery. For further insight into this specific scenario, providers are forced to consult other literature such as that published by Ueda et al, 46 the Society of Surgical Oncology, 47 or the American Society of Plastic Surgeons, 48 which have all published recommendations on this very situation even more recently than CMS. However, despite their advice, these 3 organizations urge providers to rely on institutional and/or local or state policy. If a provider was to seek guidance from the state level, physicians in 15 of the 50 states would not find answers. Relating back to the breast cancer scenario described previously, only 12 states present information regarding malignancy or its related processes, none of which provide clarity on reconstruction. [6] [7] [8] 10, 14, 20, 21, 25, 28, 30, 31, 38 And as Teven and Rebecca 49 point out in their letter to the editor, many of these cancer patients may be immunocompromised, In a global health crisis as serious as the COVID-19 outbreak, where the risk of disease transmission to patients and healthcare workers is high and PPE shortages loom, the need for decisive guidance is critical. In such situations, national societies and healthcare organizations need to step up to fill in the gaps of what the states cannot or will not provide. And although many national societies have chimed in, the input from multiple organizations can make it challenging for surgeons to interpret how to best conduct their practices during the COVID-19 pandemic. Ultimately, it is the responsibility of all plastic and reconstructive surgeons to operate under appropriate law while individualizing their practices to best suit the needs of their patients while being mindful of resource limitations and exposure risks. COVID-19: Recommendations for management of elective surgical procedures CMS adult elective surgery and procedures recommendations: Limit all nonessential planned surgeries and procedures, including dental, until further notice State guidance on elective surgeries Amended COVID-19 health mandate** Order of the state health officer suspending certain public gatherings due to risk of infection by COVID-19 Delaying elective surgeries to conserve personal protective equipment to test and treat patients with COVID-19 ADH directive on elective surgeries Amending Executive Order D 2020 009 to extend the temporary cessation of all elective and non-essential surgeries and procedures and preserving personal protective equipment and ventilators in colorado due to the presence of COVID-19 Recommendations on limitations of elective and non -urgent medical and dental procedures Accessed April 10, 2020. 10. Florida. Emergency management-COVID-19-nonessential elective medical procedures Kemp issues new executive orders, provides COVID-19 update COVID-19 -elective surgical procedure guide Executive order 20-13 Proclamation of disaster emergency Cabinet for Health and Family Services Office of Legal Services Continuation of LDH notices and orders due to COVID-19 outbreak Governor announces significant recommendations & signs civil emergency proclamation to respond to COVID-19 in Maine Directive and order regarding various healthcare matters elective invasive procedures in hospitals and ambulatory surgical centers during the COVID-19 outbreak Temporary restrictions on non-essential medical and dental procedures Directing delay of inpatient and outpatient elective surgery and procedural cases during COVID-19 peacetime emergency COVID-19: Elective surgical procedures must be rescheduled Directed Health Measure Order 2020-009 Executive Order No. 109 Public health emergency order imposing temporary restrictions on non-essential health care services, procedures, and surgeries Suspension and modification of laws relating to the disaster emergency State of North Carolina Department of Health and Human Services Director's order for the management of non-essential surgeries and procedures throughout Ohio Seventh Amended Executive Order 2020-07 M1HGGIK0N0JO00QO9DDDDM3000-2f62554c-8a45-4fe2-84a0-88ff636c3296-n3GNZ-y Conserving personal protective equipment and hospital beds, protecting health care workers, postponing non-urgent health care procedures, and restricting visitation in response to coronavirus (COVID-19) outbreaks. 2020 Available at https://www.health. pa.gov/topics/Documents/Diseases%20and%20Conditions/ Guidance%20on%20Ambulatory%20Surgical%20Facilities'%20 Responses%20to%20COVID-19 Executive Order 2020-12 An order to reduce the spread of COVID-19 by limiting non-emergency healthcare procedures Executive order GA 09 State public health order Suspension of all non-essential adult elective surgery and medical and surgical procedures COVID-19): Frequently asked questions Restrictions on non urgent medical procedures Executive order no. 16-20 See coronavirus cases by day for each Ohio county COVID-19: Data Archive Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection Our experiences on plastic and reconstructive surgery procedures during COVID-19 pandemic from Shanghai Ninth People's Hospital. Plast Reconstr Surg Global Open The COVID-19 pandemic -changing lives and lessons learned Current trends in postmastectomy breast reconstruction Managing cancer care during the COVID-19 pandemic: agility and collaboration toward a common goal Resource for management options of breast cancer during COVID-19 COVID19-Breast-Reconstruction-Statement. pdf?utm_source=Adestra&utm_medium=email&utm_ campaign=COVID-19-Breast-Reconstruction-Statement&utm_ term=Varies&utm_content=PDF Coronavirus and the responsibility of plastic surgeons. Plast Reconstr Surg Global Open