As COVID cases grow, NC hospitals are once again delaying non-emergency procedures
Last March, as hospitals in New York and Italy were being overrun with COVID-19 patients, hospitals in North Carolina canceled non-emergency surgeries and other procedures to free up beds, workers and supplies to battle the coronavirus.
Now, as they struggle to keep ahead of the growing number of COVID-19 patients in the state, some North Carolina hospitals are again delaying procedures, though in a more limited and strategic way.
Some hard hit hospitals have halted so-called elective surgeries or stopped scheduling future ones. Others, such as WakeMed, are reviewing their surgical schedules daily to determine which cases can be pushed back a few days or a couple of weeks to keep from filling too many beds at once, said Dr. Chris DeRienzo, the chief medical officer.
“We are really, really cautious about scheduling cases where people are going to need an inpatient stay,” DeRienzo said.
Orthopedic surgeries are among those that can be delayed, if a patient’s condition is not debilitating, but all procedures are reviewed on a case-by-case basis, DeRienzo said. A patient may need a heart catheterization immediately, but doctors may be able to put off a procedure to address a heart rhythm problem, he said.
The delays are among several steps that hospitals are taking to maintain capacity in the face of growing COVID-19 cases. As of Tuesday, 3,781 people were hospitalized with COVID-19, including 813 in intensive care — both new records, according to the state Department of Health and Human Services.
Hospitals across the state are adjusting by repurposing rooms and reassigning staff. In western North Carolina, where rural hospitals fear running out of both, five small hospitals asked the Christian humanitarian group Samaritan’s Purse to construct a 30-bed emergency tent hospital on the grounds of Caldwell UNC Health Care in Lenoir to treat COVID-19 patients.
“It’s sobering to see that happen,” said Tatyana Kelly, vice president of planning, strategy and member services for the N.C. Healthcare Association, the hospital trade group. “This is an honest-to-God field hospital.”
In the Triangle, Johnston County’s hospitals in Clayton and Smithfield have been at or near capacity since the week after Thanksgiving. UNC Health spokesman Alan Wolf said both had paused non-emergency surgeries through Monday to free up space and resources to care for COVID patients and have now extended the move until Jan. 11.
“They will make a determination later this week if they can restart elective surgeries next week,” Wolf wrote in an email.
UNC Rex hospital has stopped scheduling many orthopedic and bariatric surgeries because of the surge in COVID patients, said Dr. Linda Butler, the chief medical officer. Butler said the hospital isn’t canceling anything yet, but it is not scheduling new procedures that can be delayed for a month or two.
“We have probably decreased our electives that require a bed by about 25%,” she said in an interview.
Like the hospitals in Johnston County, Rex has been full at times in recent weeks, Butler said. She said when its 439 licensed inpatient beds fill up, Rex has had to keep patients overnight in the emergency department, post-operation recovery rooms and observation rooms where doctors usually monitor patients to determine whether they should be admitted.
“A couple of weeks ago, we had 550 patients spend the night in our hospital,” she said. “That tells you how beyond full we are.”
Rex had 75 COVID-19 patients on Monday, including about 16 in the ICU. Butler said coronavirus patients require more attention from doctors, nurses and therapists than typical patients and stay in the hospital eight days on average, compared to a day or two for most surgical patients.
While the hospital has some control over the surgeries it performs, she said, “We can’t control who shows up in our ER with COVID.”
Hospitals in a different position this time
The decision to put off some hospital procedures last spring grew out of uncertainty over how severe the pandemic would become and how long limited supplies of masks, gowns and other personal protective equipment would last.
Many hospitals made the move voluntarily. But state Secretary of Health and Human Services Mandy Cohen requested that starting March 23 hospitals and ambulatory surgery centers suspend all procedures and surgeries that could be delayed four weeks without causing harm to the patient.
PPE supplies are stronger now, which is why hospitals are not delaying outpatient procedures that won’t result in someone spending the night. And hospitals have gotten better about managing their resources to adjust to shifting demand, said WakeMed’s DeRienzo.
“We kind of learned how to move up and down on the gas pedal,” he said, in contrast to the “sledgehammer” approach of canceling all non-emergency procedures last spring. “We just know so much more now that will keep us from having to do that.”
Hospitals also saw that wholesale delays in procedures resulted in some patients being sicker or worse off when they finally got treatment, said Katie Galbraith, president of Duke Regional Hospital.
“We don’t want to have to be delaying care anymore, because what we ended up with was a lot of patients down the road that really needed it,” Galbraith said.
Galbraith said Duke’s three Triangle hospitals are being careful about scheduling procedures.
“At this point, we are not postponing or delaying care,” she said. “But we are reviewing on a daily basis all of our surgical cases to understand the need for that surgery and how that fits in with any capacity constraints that we may have.”
Hospital staffing the biggest challenge
Kelly, with the hospital association, said no part of North Carolina has been spared the strain that the pandemic has put on hospitals. She says hospital administrators often tell her they have enough beds but lack the trained nurses and other personnel to staff them.
“Staffing continues to be the greatest challenge right now,” she said. “A lot of that has to do with the fact that staff also occasionally get sick themselves. They’re also tired. This is a fairly intense pace to maintain as long as we have.”
Unlike other medical disasters, this one is international, Kelly notes, so there’s no pool of health care workers from outside the region from which to recruit. She said traveling nurses, who normally fill in for hospitals that are short-staffed, have become a hot commodity.
“Everybody’s trying to draw on that, and that’s causing exorbitant rates for traveling nurses,” she said. “And that puts a financial strain on facilities, and certainly smaller facilities, that aren’t able to meet that price.”
Kelly said the 30 beds in the Samaritan’s Purse field hospital are helpful, but more importantly the organization is able to recruit volunteer doctors, nurses and others from around the country to staff them.
Hospital administrators say they don’t think the pandemic has peaked in North Carolina and that they worry about another surge after holiday gatherings. COVID-19 hospitalizations have roughly doubled in the state since Thanksgiving, and the number of new cases reported by the state has averaged more than 6,000 a day in the past week.
“I had hopes that people would limit their travel and limit their contacts,” Kelly said. “But the numbers are not showing that.”
This story was originally published January 6, 2021 at 8:00 AM with the headline "As COVID cases grow, NC hospitals are once again delaying non-emergency procedures."
