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COVID-19: Reintroduction of Elective Surgery

22 April 2020

Updated 24 April 2020

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) acknowledges the risk posed to the community, health workers and all patients due to the Covid-19 pandemic. 

As the national response in Australia and New Zealand to the pandemic began, RANZCOG raised the importance of hospitals considering a reduction, or cessation, of elective surgical procedures in preparation for a potential surge in hospital admissions.
 
Following the successful “flattening of the curve”, the Australian Government has released new advice (Tuesday, April 21, 2020) and the New Zealand government has announced that the country can move out of alert level 4 lockdown at 11.59pm on Monday 27 April and move to alert level 3.
 
The following advice is subject to change and outlines RANZCOG’s initial interpretation of the advice of both governments.

Advice regarding Category 1 (Australia) or Urgent (New Zealand) classification is unchanged. Read it here.

Ensure that there are compelling reasons for surgical management at this time. Medical management of disease e.g. for heavy menstrual bleeding, pelvic pain, endometriosis is usually first-line, but where medical management is not indicated, or is unsuccessful, surgery may be indicated. Perhaps the best discriminator is the degree of dysfunction experienced by the individual patient, which is best determined through consultation between the doctor and the patient herself.

When booking non-urgent (New Zealand) or Cat 2/important Cat 3 (Australia) patients for surgery, the following factors need to be considered: 
 
  1. Decision making principles. This should include factors such as transparency, consistency, equity, fairness, duty of care, duty to steward resources, and accountability.
     
  2. Patient selection. This should be administered at a regional level, involving discussions between surgeons, anaesthetists, intensivists, and hospital administrators. Prioritisation of patients for elective surgery needs consideration of the following factors; patients with low/no risk of Covid-19, procedures that require low resources (PPE, post-operative HDU/ICU, short length of stay), additional patient risks e.g. older age and coexistent morbidities, the chance of harm if a treatment course cannot be continued (worsening Covid-19 status), geographical and inter-regional travel considerations.
  1. Ongoing monitoring of various safety and quality variables. This needs to occur at both a regional and national level, taking into account PPE usage and supply, ICU bed capacity, hospital bed capacity and community transmission rates
  1. Preparedness to scale back/stop non-urgent elective surgery.

 
Access to operating lists will be determined by theatre availability, compliance with Government guidance/directives, clinical risk and need, and requires a whole of organisation approach. RANZCOG recommends that this be deferred to the hospital administration in consultation with a senior clinical leadership group. Broader considerations include local hospital bed and theatre capacity, staffing, finite resources, and local community transmission rates.. RANZCOG encourages our members to work cooperatively with the local hospital/DHB administrators during this transition time.

 
New Zealand Ministry of Health 
 
Advice on Health and disability services at Alert Level 3 (and 2) can be found on: https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-current-situation/health-and-disability-services-alert-level-3
 
A detailed fact sheet is available: https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-current-situation/health-and-disability-services-alert-level-3#factsheet
 
Key points outlined in this advice are:
- Services will open and operate normally where possible, while managing public health risks.
- Strict hygiene measures and physical distancing measures will remain in place. Personal protective equipment (PPE) will be used when required.
 
For Hospital services:
It is important to note that the Government’s COVID-19 4-level alert system and the National Hospital Response Framework alert levels serve different purposes. The Government’s COVID-19 alert system is being implemented as a response to help break the chain of transmission across all New Zealanders. It is appropriate that district health boards (DHBs) continue to operate services as per the National Hospital Response Framework. This should enable DHBs to continue to deliver as much clinical care and surgery as possible, while preparing for the next level of readiness.
 
The National Hospital Response Framework sets out the matters that must be considered when making decisions to defer non-urgent treatment or to change service models to online/telephone. Decisions must consider equity and the clinical risk associated with delay or changes to treatment and take steps to mitigate harm or deterioration, for example, regularly reviewing the waiting list for planned care to assure that risks remain manageable for patients.
 
Hospitals will remain open for the acute and emergency health needs of the population at all levels. Planned care, including elective surgery and radiology, will be provided in order of clinical priority. Depending on the demand for hospital services (including as a result of both COVID-19 and other non-COVID conditions and needs), some non-urgent services or treatment may be deferred in order to manage pressures. Outpatient appointments will continue dependant on demand but should be managed wherever possible via online/telephone/non-contact methods.



 
Prime Minister of Australia
Media Statement April 21 2020
Elective surgery

 

National Cabinet received up-to-date data on the stock of personnel protective equipment (PPE) in the National Medical Stockpile, and PPE held by state and territory health systems. PPE stocks and other equipment such as ventilators are now largely sufficient to meet expected demand for Australia’s COVID19 response through to December 2020, with current social distancing and travel restriction measures in place. 

National Cabinet noted that the National Medical Stockpile does not replace state, territory or private processes to source and deliver PPE to meet their needs. To date, the National Medical Stockpile has dispatched over 22 million masks primarily to state and territories, GP’s, Community Pharmacy, ACHHOS and aged care, with a further 11.5 million being dispatched this week.

Unnecessarily delaying elective surgeries can worsen health outcomes, increase anxiety and reduce social and economic productivity. 

As result of Australia’s success in flattening the curve, our low rates of COVID related hospitalisation and new data on stocks of PPE, National Cabinet agreed that from 27 April 2020, category 2 and equivalent procedures can recommence across the public and private hospital sectors. 

As result of Australia’s success in flattening the curve, our low rates of COVID related hospitalisation and new data on stocks of PPE, National Cabinet agreed that from 27 April 2020, category 2 and some important category 3 procedures can recommence across the public and private hospital sectors. 

National Cabinet further agreed that the following procedures can recommence from 27 April 2020:

  • IVF
  • Screening programs (cancer and other diseases)
  • Post cancer reconstruction procedures (such as breast reconstruction)
  • Procedures for children under 18 years of age.
  • Joint replacements (incl knees, hips, shoulders)
  • Cataracts and eye procedures
  • Endoscopy and colonoscopy procedures

PPE stocks for these elective surgeries and procedures will not be taken from the National Medical Stockpile.

It is estimated that a gradual restart of elective surgeries will see 1 in 4 closed elective surgery operating lists reopen, with flexibility for states to determine the appropriate levels of elective surgery within this general framework.

Reintroduction of elective surgery in a staged manner balances the ongoing need for the capacity to treat COVID-19 patients, while allowing our hospitals to treat elective surgery patients.

These arrangements will be reviewed by 11 May 2020, to determine if other elective surgeries and procedures can recommence and volumes increased.

National Cabinet further agreed to the Australian Dental Association recommendation that dentists move to level 2 restrictions (such as fitting dentures, braces, non-high speed drill fillings and basic fillings), allowing a broader range of dental interventions to occur where the risk of transmission can be managed and PPE stocks procured by the private sector.

National Cabinet again thanked Australia’s health care professionals for their work to support our COVID-19 response.

Source: https://www.pm.gov.au/media/update-coronavirus-measures-210420




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