Hospitals are expected to receive the go-ahead this week from Gov. Bill Lee to resume elective surgeries, though they haven’t reached the cataclysmic numbers of COVID-19 patients predicted in early models.

“We’re working with the (Tennessee) Hospital Association to get those opening times and the guidance just right,” Lee said Friday, April 24, as he announced plans for restaurant and retail openings outside metro areas for Monday, April 27, and Wednesday, April 29.

The state’s “safer at home” order is set to expire April 30, and restaurants and retail stores will start opening in 89 rural and suburban counties Monday and Wednesday on a limited basis. Memphis and other urban areas are setting their own time frames and plans.

A month ago, the governor feared Tennessee would be 700 hospital beds short of the number needed to care for an influx of COVID-19 patients. That projection spurred his Unified Command to work with the U.S. Army Corps of Engineers to identify places such as the Music City Center in Nashville to house extra beds in case of a dire situation. Those plans, as well as the need for several locations in Memphis, were put on hold when demand for hospital beds dwindled in a matter of days, but a field hospital is being built to open May 14 in Memphis at the former Commercial Appeal site on Union Avenue. 

COVID-19 field hospital conversion underway on Union Avenue

Lee banned elective surgery in Tennessee on March 19, shutting off about 45% of the revenue stream that most hospitals in Shelby County count on from outpatient procedures.

Hospital revenues dropped “dramatically” as inpatient and outpatient procedures have fallen while costs for personal protection equipment, which has been in short supply, have increased, according to Tennessee Hospital Association spokeswoman Kristin Day.

In fact, a recent THA analysis found hospitals are experiencing negative financial impact of $1 billion a month because of the pandemic, Day said in response to questions from The Daily Memphian.

“These facilities have maintained expensive operations in preparation for and to serve COVID-19 patients while experiencing a dramatic drop in volume and services that typically comprise their core business,” Day said. “This creates a paradox of hospitals experiencing severe financial strain when their services are most needed.”

THA is working on a plan with hospitals to resume elective surgeries, based on their community and circumstances, she said, noting state and federal funds are important for keeping hospitals open and ready for a surge of patients. 

Tennessee adds 460 cases, largest daily increase to date

Shelby County hospitals had a surge capacity of 3,192 beds as of April 23. Only 51 COVID patients were being treated in acute care beds and 43 in intensive care units, while the status of another 71 patients was under investigation.

The county’s hospitals had 1,875 people out of 2,732 staffed beds, 69% in acute care and 332 ICU patients being treated out of 475 staffed beds available, 70%.

Only 35% of negative pressure rooms, 124 of 355, and 33% of ventilators, 227 of 691, were in use. Of those, 13 were COVID patients and seven more were under investigation.

The federal government is expected to send $3.6 billion to Tennessee as part of the $2.2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act, and some of it will be used to bolster hospitals during the pandemic.

“Those dollars will be forthcoming and that’ll provide assistance specifically to hospitals in every part of the state,” Lee said.

Some Tennessee hospitals, such as Saint Francis in Memphis, have furloughed employees during the crisis as a result of the executive order to restrict elective surgeries to ensure the state would have enough beds to deal with a doomsday forecast.

While that projection didn’t hold true, at least for now, the state made grants from a $10 million fund to four rural hospitals and is set to dole out more funds to rural hospitals this week. The first recipients were in Fayetteville, Waverly, Henderson County and Lauderdale County, according to Lee, and those hospitals also have drawn down $7.5 million in federal funds.

Most of Tennessee’s rural counties have relatively few reported cases. But House Democratic Caucus Chairman Mike Stewart points out rural areas need only one infected person to go into a nursing home or a factory and the number of cases could increase dramatically.

The state had 8,726 positive COVID cases Friday, with 168 deaths and 808 total hospitalizations. Nearly 4,400 people have recovered.

Sen. Bo Watson, a Hamilton County Republican who chairs the Senate Finance, Ways and Means Committee, says the state didn’t have enough information to determine the impact of the coronavirus on hospitals and, based on national models, prepared for the worst scenario instead of underestimating the number of people who could get sick.

The prohibition on elective procedures was designed in advance of a surge, “which has not happened, which is a good thing,” Watson said.

In Memphis, Campbell Clinic surgeons plan to work expanded hours starting in early May, to get through 40-plus days of elective surgeries delayed because of the coronavirus.

Their partner hospitals have said they will extend operating room hours, including weekends, to support the effort.

“It won’t take long,” said Dr. Fred Azar, Campbell’s chief of staff. “We’re going to be basically working long hours to get them done.”

To prepare for the load, he said, hospitals in the Memphis region have been checking with physicians about cases on their waiting lists.

The metro counties are working with the statewide task force on how to proceed. All businesses will be responsible for monitoring social distancing and providing protective gear for their employees.

“Our patients have always anticipated the best-case scenario,” Azar said. “Once the governor said the end of April, everyone was hopeful he wouldn’t extend his executive order, and he didn’t extend it. So, we have tentatively been planning, our patients have, for that all along.”

The clinics and Campbell’s two ambulatory centers, he said, are following the plan set out by the governor and task force for reopening, which outlines steps for admitting patients for elective surgery.

Campbell will do a telephone screening first, as it has been doing during the stay-at-home order, for its clinical patients.

“We’re making sure they are not sick or have not been exposed to anyone who had COVID. They don’t come into our clinic or surgery centers until that has been sorted out,” Azar said.

The doctors also are required to watch for new outbreaks in populations around the city or surgery centers and to respond accordingly.

Every hospital will interpret the plan differently, according to Don Bivacca, managing director of Healthcare Management Partners, a health care financial consulting firm in Nashville.

“But there are a couple of things that are mandatory in terms of Gov. Lee allowing this thing to go forward.”

The first is that hospitals and ambulatory surgical centers must have enough personal protective equipment – gloves, masks and gowns – to safely open elective and nonessential surgeries.

They will be required to pretest surgery candidates and test again the day of surgery to make sure the patient is COVID-19-free.

“The ambulatory centers will probably be the second to actually open because they probably won’t have the ability to test and get a result as quickly as a hospital will be able to,” he said.

Neither Baptist Memorial Healthcare nor Methodist Le Bonheur Hospital systems wanted to discuss when they would return to normal elective surgery schedules or the process for deciding.

“The decision on elective surgery has really been the focus of a lot of discussion in the last few days,” Shelby County Mayor Lee Harris said Friday in the daily COVID press briefing. ‘”I think it is going to become a phased-in approach because to the extent you can create revenue streams for hospitals – like returning elective surgeries – they will be in a better position to stabilize, to not furlough their employees and make sure they have staff and bed capacity in place when the (expected coronavirus) surge occurs.”

Saint Francis furloughed about 250 employees last week, telling some they should not expect to be called back until mid-July.

Even if the metro counties decided to entirely open elective surgery on May 1, Bivacca thinks most hospitals wouldn’t be able to respond that quickly, because they have closed portions of their organizations or furloughed workers.

But what they can do, he said, is start the diagnostic work required for the procedures.

“A lot of these types of procedures require some diagnostic work, an MRI for knee replacement or CT scan or lab work to ensure things haven’t changed from the last time the doctor actually looked at the person’s knee.”

Hospitals, he said, will be choosing the patients this week, ordering diagnostic work and beginning to schedule nonessential surgeries.

“In two to three weeks, you’ll probably see some hospitals will have performed elective surgeries, and they gradually will be allowing more and more to come in. But they are not going to do any surgeries on COVID patients.”

The irony at Campbell, Azar says, “Is we have people sitting home when they could have been recovering from their surgeries. We had to circle the wagons and preserve our PPE, especially the hospitals, in the event we needed the resources and beds.

“Now that procedures are going to be allowed, we have patients that are going to be asked to go back to work. Some of them need to have procedures done just when they need to get back to work,” he said.

He suspects many elective surgeries will be put off because people can’t afford more time off or because they lost the jobs that provided their insurance.

“Some of these things – colonoscopies, breast biopsies, prostate biopsies – need to be done or potentially lead to problems.”

The waiting list is being scheduled based on the urgency of the patient’s need.

“The physicians who have been taking care of our patients know who needs to be done sooner,” Azar said.

“I think we’ll catch up in four to six weeks, and then we will have to prepare for the new normal. It’s going to be different. We anticipate we’ll be seeing fewer patients,” he said.

State Sen. Katrina Robinson isn’t convinced the end of the virus is at hand. The Memphis Democrat spent a month working with COVID-19 patients at Bellevue Hospital in the Manhattan borough of New York City, America’s epicenter for the disease.

Robinson is worried the different time frames for reopening the state’s economy could spur a surge in Tennessee cases. 

Memphis hospitals aren’t overwhelmed yet, but they could be inundated at any moment, with personnel going in and out of rooms, from environmental services to laboratory and respiratory therapy personnel, she said.

“It just takes one person to contract it and carry it, and you have the whole hospital that’s now infected,” Robinson warned.