County follows order, suspends certain elective surgeries
Staffing issues, bed capacity fuel measure
SANTA CRUZ >> A local health order signed by Santa Cruz County Health Officer Dr. Gail Newel on Tuesday will prohibit low and intermediate acuity surgeries for the foreseeable future.
The order went to effect Thursday.
According to the order, live on the County of Santa Cruz Health Services Agency website, the call is being issued in response to critical shortages of staffing, regular and ICU bed capacity due to the coronavirus pandemic’s surging demand on the health care systems in the county. The decision aligns with that of a state-level order signed by State Public Health Officer Dr. Tomás J. Aragón on the same day earlier this week in order to prioritize services to those illest and resources to those who must care for them.
On Tuesday, as Newel signed the order, the state reported through its metrics that Santa Cruz County had five open ICU beds or 23% of its 22 total beds between Dominican Hospital and Watsonville Community Hospital. Regionwide, the Bay Area had 5.9% ICU capacity. Just before the order went into place at 5 p.m. Thursday, the county had four beds available and a regionwide capacity of 3.5%.
In both cases, the county hadn’t yet fallen into the group that had to abide by the state order: a county in a region under the regional stay-at-home order that has 0% ICU availability and the California Department of Public Health calculation for the ICU availability for that county is 10% or less. But across the state the situation is dire, both orders suggest.
“As resources become constrained, from facilities to supplies to staffing, systems shift from conventional care into contingency care,” State Public Health Officer Dr. Sonia Angell, said in June of last year, in a document titled “California Sars-CoV-2 Pandemic Crisis Care Guidelines” before the first surge in California — a summer spike around Fourth of July. “Crisis care falls at the far end of the spectrum when resources are scarce and the focus shifts from providing the best care for the individual patient to delivering the best care for the patient population.”
Angell went on to explain that surge capacity is described across a spectrum of three categories: Conventional (usual resources and level of care provided), contingency (functioning with equivalent care that is adapted from usual practices due to shortened resources) and crisis (when high demand and low resources force the hands of health care workers to use strategies that pose a bigger risk than adapted contingency practices, such as cot-based care).
Preventative step
The preventative step of a local order was initiated in order to avoid a crisis-care status situation, Newel wrote. This reveals that Santa Cruz County hospitals and ambulatory surgery centers, referred to in the order as “facilities,” are already operating from a contingency care standpoint, that space, staff, supplies and the level of care have already changed as local, state and federal health officers predict the holiday season will have caused a surge- on-surgeon-surge situation.
The guidelines for surge care show that hospital and surgery center staff may have already taken state-requested actions such as a change in the use of pre- anesthesia and pre- operation unit beds as well as converting single beds to doubles. Staff may have started to work longer shifts and models around configuration and supervision may have already changed. The motto around supplies is likely “Conserve, adapt, substitute and re-use,” a figure in the document says. The level of care may be equivalent but delayed.
If the county moves into crisis status, patients can expect to be treated with cot-based care and the level of care stepped down in ICUs. Staff will likely deal with a higher ratio of patients to nurses or patients to doctors, supplies will be rationed and the standard of care may include triaging medical attention and ventilators.
‘Disaster care’
Recent protests facilitated by nurses at Watsonville Community Hospital allege that longer shifts and more patients to medical professionals are practices that have already been instituted at centers in the area.
To avoid what the CDPH describes as “disaster care,” the order will take the strain off health care workers who have been serving both run of the mill surgery patients and those with severe COVID-19 symptoms. It will also spare the public of a large risk: the risk COVID-19 patients with “less severe” symptoms would be released and community transmission, which currently makes up the exposure source for less than 5% of Santa Cruz County cases, would become a sincere issue.
“When hospitals are overwhelmed, they are unable to provide care meeting appropriate medical standards or to implement appropriate infection control measures needed to prevent further spread of COVID-19 disease in the healthcare setting,” Aragón wrote in his introduction to the state order. “If hospitals lose the capacity to care for seriously ill COVID-19 cases, those highly infectious COVID-19 patients will be pushed into the general community which will further increase community transmission.”
Tiers 1 and 2
The local and state orders call for surgeries organized in Tier 1 and Tier 2 of the St. Louis University Elective Surgery Acuity Scale, a model for non-emergent operations recommended by the American College of Surgeons.
Low acuity surgeries for healthy patients, such as outpatient surgeries for non-lifethreatening illnesses like carpal tunnel or a colonoscopy fall into Tier 1a. Low acuity surgeries for unhealthy patients make up Tier 1b. Intermediate acuity surgeries for healthy patients, surgeries for non-life-threatening issues that could add to morbidity in the long-run, such as low-risk cancer operations fall into Tier 2a. Tier 2b includes intermediate acuity surgeries for unhealthy patients. In all four of these subcategories, the recommended action is postponing the surgery if possible or performing them at an ambulatory surgery center rather than a hospital.
Hospitals were already adapting to the order Thursday.
“Dominican Hospital has stopped elective surgeries consistent with the County of Santa Cruz Health Services Agency order,” Dominican Hospital President Dr. Nanette Mickiewicz said.