Intermountain's Position on Updated State Guidelines for Surgeries and Procedures

Earlier this week, the state rescinded the March 2020 health order that had restricted certain types of surgeries and procedures to mitigate the spread of the COVID-19, to keep caregivers and patients safe, and to conserve resources to respond to the pandemic and help prepare for a possible surge. In light of the reduced number of COVID-19 hospitalizations in Utah and the demand to resume certain surgical procedures, the State is providing new and cautious guidance consistent with revised recommendations from the Centers for Medicare & Medicaid and a joint statement from national surgical societies. 

We are providing additional guidance and clarification on what this means for Intermountain Healthcare as the state moves from a RED to an ORANGE classification of community COVID-19 risk in the Governor’s plan for pandemic stabilization and recovery. Intermountain reaffirms our commitment to caring for our patients while abiding by guidelines that will minimize additional spread of COVID-19, to ensuring safety for our caregivers and patients, and to continuously monitor our resources and supplies to adjust plans as needed. 

1. When will these additional surgeries and procedures be allowed?
   With the new State Health Order in place, we are planning to begin rescheduling some surgeries that fit state criteria beginning the week of April 27. This will be a rolling start, allowing for individual facilities to make necessary preparations for additional cases.
   
   
2. What surgeries are now allowed under the updated guidelines?
   Under the ORANGE classification, we’ll continue to perform surgeries for emergency care, and medically necessary, time-sensitive cases that are intermediate acuity [please see Appendix below]. We will also add ambulatory surgeries (no overnight stay) for patients with intermediate acuity treatment needs as determined by their physician and the facility OR (Operating Room) Council, and who have a low risk for COVID-19 complications. 
   
   We will still postpone surgeries that:
   a. Require an admission to a hospital or step-down facility and are not time sensitive
   b. Are low acuity
   c. Involve COVID-19 positive patients whose surgical needs are not emergent
   d. Involve patients at greater risk for more severe COVID-19 illness
   
   
3. How do the State’s updated guidelines impact procedures other than surgery?
   
   Office-based Procedures and Visits
   At this time, we are following our existing guidelines. We have organized teams of clinical and operational leaders to evaluate potential updates and next steps. 
   
   CV Procedures (CV Surgery, Thoracic Surgery, Vascular Surgery & Cardiac Cath Lab Cases)
   Individual cases will be evaluated and prioritized based on acuity, capacity, and safety utilizing similar guidelines as surgery. CV Clinical Program Associate Medical Directors (AMDs) will continue to work with their surgical and catheterization lab leaders and each provider on appropriate scheduling and risk-based pre-op/pre-procedural testing. Further CV-specific guidance on procedures and cardiac imaging is forthcoming from the CV Clinical Program.
   
   Endoscopy Procedures
   Endoscopy procedures (upper endoscopy, colonoscopy, bronchoscopy) that involve sedation will be reviewed by the same process as for surgery. Screening endoscopy (such as screening colonoscopy) will continue to be postponed. 
   
   Imaging 
   While some additional imaging studies will be scheduled – specifically imaging for approved surgical procedures – we will continue to postpone imaging procedures and tests that are non-urgent or not time sensitive.
   
   Sleep Labs
   No changes – follow existing guidelines. 
   
   Infusion Centers 
   No changes – follow existing guidelines. Evaluation is taking place.
   
   Radiation Therapy
   No changes – follow existing guidelines. 
   
   
4. Will all surgical patients be tested or evaluated for COVID-19 prior to their surgical procedure?
   Yes. A process for ordering the test during the patient’s pre-anesthesia screening will be implemented. 
   
   
5. How will surgeons schedule patients who now meet criteria?
   Our Surgical Ops team will be reaching out to surgeons and their offices to have them identify patients who now meet criteria. Those cases will be reviewed by facility OR (Operating Room) Councils, which have been in place since mid-March.
   
   
6. When the time comes to reschedule non-urgent in-office procedures, will there be a governance process similar to the OR Councils, to review these cases?
   Yes, the Intermountain Medical Group as well as other ambulatory, non-hospital-based teams and physician leaders are working on a process to support safety and quality in loosening our current restrictions for in-office procedures. Look for more communication that will be coming in the next week(s).
   
   
7. Do we have adequate staff, supplies, etc., to accommodate these additional surgeries that will be allowed under an ORANGE status?
   Surgical Ops is collaborating closely with Supply Chain, Pharmacy, Planning, Operations, and Incident Command. Based on our best modeling, we feel confident we are in position to accommodate these additional cases. That said, we will closely monitor the COVID-19 status in the community, surge status, supply inventory, as well as our staff and make appropriately adjustment as needed.
   
   
8. Will patients need additional pre-authorization for their surgery or procedure?
   SelectHealth and most other plans do not need a follow-up communication to reinitiate authorizations for services that were previously approved and will be provided before the end of 2020. We are encouraged that most payers are allowing this flexibility and are accommodating extensions for pre-authorizations for varying periods of time. However, at this time, please contact payers other than SelectHealth to confirm that the authorization is still valid. Payer Contracting is developing a payer-specific document that outlines the timeframe for which each payer will extend pre-authorizations. We expect to have this document ready early in the week of April 27, and caregivers will then have more definitive information about the payers from which they need to obtain updated authorizations. 
   
   
9. What health systems are contributing to the guidelines being put into place by the Utah Hospital Association as they relate to the color stages in the Governor’s Utah Leads Together 2.0 plan? The Chief Medical Officer (CMO) Group consists of members from the Hospital Corporation of America, Steward Health, Intermountain Healthcare, University of Utah Health, and the independent rural hospital facilities. The Utah Hospital Association, through its CMO Group and in conjunction with the Utah Department of Health, developed protocols to resume procedures in Utah’s hospitals. The Utah guidelines are based upon the joint statement from the American College of Surgeons, American Society of Anesthesiologists, Association of peri-Operative Registered Nurses, American Hospital Association, and guidance from Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention. 
   
10. Why is this classification for surgery being used?
    The classification was adopted by CMS and the American College of Surgeons recommendations. It is based upon the Elective Surgery Acuity Scale from St. Louis University acuity [please see Appendix below] and has become a common nomenclature at national and local levels. For this reason, it continued to be adopted in the development of the Utah Hospital Roadmap for Resuming Elective Procedures. 
    
    
11. Who is coming up with assigning the procedures that belong in each classification?
    Based upon guidelines from CMS, national societies, collaboration with colleague health systems, and guidance from the clinical programs, a sampling of procedures has been assigned to assist physicians in their scheduling of patients for surgery. 
    
    
12. Are Tier 1 procedures allowed under these guidelines if it does not require a hospital (or extended care facility) admission and if the patient is low risk? 
    No. Tier 1 procedures are not being performed under the risk level conditions of ORANGE. 
    
    
13. So if a procedure is elective ambulatory but it’s in the Tier 1 category, it still is not allowed even if the patient doesn’t need admission and is in a low-risk population?
    That is correct. Even if a Tier 1 procedure on a low-risk patient will not require an admission it is not a procedure that is appropriate to be scheduled while the risk level is at ORANGE.
    
    

Appendix A: Surgery Acuity Scale    
Modified from St. Louis University classification endorsed by the American College of Surgeons

High Acuity Across Specialties - Life/Permanent Organ Damage Threat

• Hemorrhage
• Sepsis
• Ischemia
• Obstruction
• Replantation
• Deceased donor transplantation
• Airway