Even as they struggle to keep pace with a pandemic at its peak, hospitals are preparing for something almost as challenging: what comes next.
It is a delicate phase of the coronavirus crisis, the need soon to bring back hundreds of patients whose procedures and appointments were canceled or postponed to make room for those with COVID-19 — and assuring those patients it’s safe to return.
The eventual shift will require hospitals to screen more — and perhaps all — patients for the coronavirus, so as to safeguard the right staff with special protective equipment. It will require, for a time, prioritizing certain procedures and medical appointments over others, itself a fraught exercise. And it will likely require some redesign of the hospitals themselves, creating separate entrances and pathways through the institution for infected outpatients, a hospital within a hospital, in other words.
Health care providers will have to do all this knowing that they will be treating COVID-19 patients for many months to come — or at least until there is a vaccine — and will need to allay public fears about entering buildings consumed by the pandemic over the past two months.
“We have all gone from predicting the peak to predicting when we will be able to do other work that has been deferred. In all scenarios, there will be COVID,'' said Dr. Alastair Bell, chief operating officer at Boston Medical Center. "We are going to be managing in a dual world for some period of time, even for a long time.''
As they develop plans for this next phase, several of the state’s large hospital systems said they will test for the coronavirus among all patients who they expect to admit to the hospital, even if they don’t have symptoms. The results will guide decisions on how to protect staff and where to locate patients. Massachusetts General, Brigham and Women’s, and 10 other hospitals in the Partners HealthCare System began testing all patients Monday.
Patients coming for outpatient appointments can expect to be isolated if they have the coronavirus or are at risk for it — even required to use separate parking areas, entrances, and elevators from uninfected patients — to help keep the virus from spreading.
Hospital leaders across the state are now prioritizing which patients have the most urgent needs and will be brought back first. Surgery to remove cancerous tumors, cardiac procedures to clear severely blocked arteries, and operations to relieve serious pain, such as kidney stone removal, are at the top of the list. Another priority is in-person visits, including blood tests and electrocardiograms, for high-risk patients such as those with diabetes and heart failure.
For certain patients, ''we have to start moving on them now,'' said Ann Prestipino, a senior vice president and incident commander at Mass. General. "They are becoming urgent or emergency cases that we have to start doing.''
A big unknown is how quickly hospitals can schedule these patients, although coronavirus modeling provides clues.
Dr. Peter Dunn, a vice president overseeing inpatient capacity management at Mass. General, expects the number of coronavirus patients in the hospital to gradually decline over the next 16 weeks — about three times as long as it took for the pandemic to hit its peak, an estimate based in large part on the experience of hospitals in hard-hit Italy.
At Mass. General, which had 301 patients hospitalized with COVID-19 on Thursday — and 108 patients awaiting test results — Dunn predicts the number of patients positive for the virus will be around 225 to 250 patients between May 11 and 18.
He said it’s hard to know ''the floor'' — Italy is not there yet and the exact rate of decline depends on local practices like social distancing.
But Dunn, whose team is also helping map "recovery plans'' for all Partners hospitals, said coronavirus cases will probably not fall to zero anytime soon. Treating the disease will become part of the new normal in health care.
Planning for the "surge was much easier,'' he said. "We had a single focus: making room. This is much more complex. People have a view of what they knew pre-pandemic life to be and they want to get back to that as soon as possible. I hope we can get as close to that as possible, as we have an understanding that it’s not going to be same. COVID is not going to go away.''
Before hospitals can schedule non-urgent surgeries, they will need clearance from Governor Charlie Baker, who ordered medical centers to cancel "nonessential elective procedures'' on March 15. Hospitals have seen declines of at least 50 percent in admitted patients and even steeper drops in outpatient appointments.
There are financial considerations, too — hospitals can go without these patients, a critical source of revenue, only for so long before they have to make deep cuts.
But even when the state allows routine medical to care to resume, hospitals are likely to open back up to patients at different rates, depending on when their coronavirus surge in cases occurred.
“There is still a fair bit of uncertainty about when we will reach the peak,'' Peter Shorett, chief integration officer at Beth Israel Lahey Health, a 12-hospital system in eastern Massachusetts, said Tuesday.
Since then, the number of COVID-19 patients in the system has declined, though its largest hospital, Beth Israel Deaconess Medical Center, still had 172 patients hospitalized with COVID-19 Friday and another 70 awaiting test results.
Shorett said certain patients cannot wait much longer for care that was delayed. "They could be rescheduled for 30 to 45 days, but they can’t be rescheduled longer without creating harm,'' he said. Even colonoscopies are a concern, given "the shear size of the backlog and the high prevalence of disease. We want to avoid being in a situation where we end up finding advanced results.''
Beth Israel Lahey Health plans to expand patient testing when it begins elective procedures again, as does Boston Medical Center and the UMass Memorial Health Care system based in Worcester. Coronavirus tests can generally be done two days before a scheduled surgery, and for patients waiting to be admitted from the emergency department, certain tests can provide an answer in two hours.
There are other obstacles to bringing back patients. Post-surgery recovery areas have been repurposed as COVID-19 intensive care units, and hospitals will need to convert them back. Anesthesiologists have been working in expanded ICUs, and hospitals must make sure they have enough of these specialists able to return to operating rooms.
Some hospitals believe that they can safely locate patients admitted with coronavirus on the same floors as other patients, as long as they follow strict infection-control procedures such as hand-washing and disinfection of reusable medical equipment. But patients with COVID-19 will not share rooms with uninfected patients. And managing outpatient clinics presents its own set of complexities.
"Do you see COVID patients in clinic at a certain time of the day? Can we do a thorough cleaning of the waiting room? Do COVID patients have to take separate elevators?'' said Dr. Eric Dickson, chief executive of UMass Memorial Health Care. "It’s the world we are going to be living in.''
Establishing special, isolated areas for patients with various medical needs who also happen to have coronavirus, is one option.
Two weeks ago, Mass. General converted part of a floor normally used for cancer patients in its Yawkey Center into an outpatient clinic for patients with coronavirus or at high risk for the disease. Doctors from different specialties can schedule visits with their patients in this space, where infectious disease specialists help them put on and take off personal protective equipment.
Patients arriving for appointments in this clinic are directed to park in a specific area of the garage and use separate elevators that are disinfected often, said Dr. Inga Lennes, a senior vice president and medical director of ambulatory services.
Given that Mass. General has more than 250 ambulatory practices in dozens of locations, it is not possible to distribute protective equipment to all these doctors, she said. Currently, 20 to 30 patients are being seen in the special clinic each day, including cancer patients who need chemotherapy infusions and post-surgery patients whose doctors must check if their wounds are healing properly. If need be, the hospital could increase capacity up to 400 patients.
Brigham and Women’s has set up a similar clinic, and other Partners institutions, including Newton-Wellesley Hospital and North Shore Medical Center, plan to follow suit.
"In the very beginning (of the pandemic), we did delay a lot of care,'' Lennes said. "It was a huge endeavor to create that space. Without it, we would have to delay care further.''
Even with all the disruptions patients can expect amid the return to somewhat normal care, hospital leaders say there are some changes caused by the coronavirus that they’d like to keep — including the flexibility that allowed the swift expansion in the number of intensive care beds and increased use of telemedicine.
At Boston Medical Center, 85 percent of behavioral health visits went online during the pandemic. As a result, rates of patients failing to show up for appointments dropped from 30 percent to 13 percent, Bell said. "There has been a rapid acceptance of virtual care. We want to continue that.''
Liz Kowalczyk can be reached at firstname.lastname@example.org.