State Guidance on Elective Surgeries

Updated: April 20, 2020

On March 14, US Surgeon General Jerome Adams tweeted that hospitals and healthcare systems should consider stopping elective procedures amid the COVID-19 outbreak. On March 18, the Centers for Medicare & Medicaid Services (CMS) also released guidance to limit "non-essential adult elective surgery and medical and surgical procedures, including all dental procedures." The guidance additionally notes that while "decisions remain the responsibility of local healthcare delivery systems...and those surgeons who have direct responsibility to their patients," when determining the risks and benefits of any planned procedures "...not only must the clinical situation be evaluated, but resource conservation must also be considered." Since the surgeon general's statement, a number of state officials have come out with their own directives and guidance regarding elective procedures, ranging from recommendations that providers scale back elective procedures to mandates that elective procedures be canceled or postponed. ASCA is tracking these official statements and any media reports of potential upcoming statements.

Currently, 36 states and Washington, DC, have released official statements or their state officials have made statements to media addressing the issue of elective procedures during the ongoing COVID-19 outbreak.

Three states (Alaska, Oklahoma and Texas) have issued orders rolling back their restrictions on elective procedures.

This resource will continue to be updated as the situation develops. All questions or new information should be directed to Stephen Abresch.

 

Alabama

Governor Kay Ivey issued a state of emergency on March 13 due to the coronavirus. As part of the emergency declaration, Governor Ivey authorized any healthcare facilities that have invoked their emergency operation plans to implement their “alternative standards of care” plans. The Alabama Department of Public Health issued a suggestion on March 13 that gatherings of more than 500 people be postponed or canceled. On March 19, Governor Ivey and the Alabama Department of Public Health issued a statewide public health order that includes a directive that “effective immediately, all elective dental and medical procedures shall be delayed.” On March 27, the state health officer released a new public health order suspending public gatherings and once again limiting elective procedures. The order provides that effective March 28 at 5:00 pm, all dental, medical or surgical procedures will be postponed until further notice, subject to the following exceptions: dental, medical or surgical procedures necessary to treat an emergency medical condition; and dental, medical or surgical procedures necessary to avoid serious harm from an underlying condition or disease, or necessary as part of a patient’s ongoing and active treatment. The order defines “emergency medical condition” as, “...a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected by a person’s licensed medical provider to result in placing the health of the person in serious jeopardy or causing serious impairment to bodily functions or serious dysfunction of bodily organs.” The order shall remain in force until 5:00 pm on April 17. On April 3 the state health officer issued a stay at home order, which includes a reiteration of the previous order on elective surgeries and provides that all orders will be in effect until April 30.

 

Alaska

Governor Mike Dunleavy has not declared a state of emergency due to the coronavirus at this time, though a coronavirus health mandate was issued March 13. The mandate suspends visitation by the general public of selected state institutions beginning March 14. On March 16, Alaska's chief medical officer issued a health alert advising that all Alaskans follow the US surgeon general’s advice and requesting that, “all patients, providers, hospitals and surgical centers…consider minimizing, postponing or canceling all non-urgent or elective procedures for three months to decrease the overall impact on the Alaska health care structure.” The alert explicitly states that the request is not a mandate. On March 19, Governor Dunleavy released Health Mandate 005 requiring that “hospitals and surgical centers...postpone or cancel all non-urgent or elective procedures for three months to decrease the overall impact on the Alaska health care structure and preserve personal protective equipment.” The order does acknowledge that the terms “non-urgent" and "elective” are not fully defined, and as such the state recommends, “...each hospital creates a physician task force that would be available to evaluate on a case-by-case basis and make a determination on borderline surgeries.” On April 7, an amendment to Health Mandate 005 was released, extending the order's requirements surrounding elective procedures to June 15. Governor Dunleavy subsequently released additional guidance regarding the mandate on elective procedures, issuing a letter that states, “non-urgent or elective procedures include, but are not limited to, those identified by the American College of Surgeons, Elective Case Triage Guidelines for Surgical Care...”.

On April 15, the state issued Health Mandate 015, which allows for the resumption of health care services contingent upon certain safety standards being met. The order provides that health care services, such as non-urgent or non-emergent elective services, that cannot be delayed beyond eight weeks without posing a significant risk to quality of life may resume May 4. The order additionally lays out a range of safety precautions that must be met in order for facilities, which explicitly include ASCs, to provide elective services.

 

Arizona

Governor Doug Ducey issued a declaration of emergency on March 11 in response to the coronavirus. In a tweet on March 15, Governor Ducey announced that Arizona will be following the CDC’s guidance that all event gatherings of 50 people or more be canceled. Governor Ducey went further to explain that "this recommendation does not apply to the day to day operation of organizations such as institutes of higher learning or businesses and applies to events of 50 people or more." On March 19 Governor Ducey issued an executive order delaying elective surgeries to conserve personal protective equipment necessary to test and treat patients with COVID-19. According to the order, beginning at 8:00 am on March 21, “...all non-essential or elective surgeries, including elective dental surgeries, that utilize personal protective equipment or ventilators shall not be performed at any licensed healthcare facility or by any licensed healthcare provider in the State of Arizona.” The order defines “non-essential or elective surgery” as surgery that "...can be delayed without undue risk to the...health of a patient" and states that licensed medical professionals "...shall use their best medical judgement in determining whether a surgery is non-essential or elective.” The order is to remain in place until further notice, and will be reconsidered for repeal or revision every two weeks.

Arkansas

Governor Asa Hutchinson declared a public-health emergency on March 11 due to the coronavirus. At this time, the Arkansas Department of Health is not offering any guidance to mass gatherings, leaving those decisions up to the organizers themselves. On March 27 the Department of Health and the Board of Optometry issued guidance recommending the, “...voluntary suspension of all non-emergency or non-urgent care or services to patients until further notice, including elective procedures.” On March 30, the Department of Health sent a guidance letter to all health facilities, including ASCs, recommending that elective surgeries be postponed statewide. On April 3, the Department of Health issued a directive on elective surgeries mandating that "procedures, testing, and office visits that can be safely postponed shall be rescheduled to an appropriate future date." The directive states that emergent and urgent care are exempt from the mandate, and states that exceptions should be made in the following circumstances: if there is a threat to the patient’s life if the procedure is not performed; if there is a threat of permanent dysfunction of an extremity or organ system if the surgery is not done; if there is a risk of metastasis or progression of staging of a disease or condition if surgery is not performed; if there is a risk that the patient’s condition will rapidly deteriorate if surgery is not done, and there is a threat to life or an extremity or organ system or a threat of permanent dysfunction or disability.

 

Colorado

Governor Jared Polis declared a state of emergency on March 11 in response to the presence of the coronavirus in Colorado. On March 18, Governor Polis issued an executive order closing the state's schools to in-person learning from March 23 to at least April 17 to guard against the spread of the coronavirus. On March 14, Governor Polis issued an executive order directing the closure of downhill ski resorts. On March 16, the Colorado Department of Public Health & Environment ordered the closure of restaurants and bars for at least 30 days. Governor Polis released an additional executive order on March 19 directing all voluntary or elective surgeries or procedures to be suspended from March 23 to April 14. The order defines "voluntary or elective surgery or procedure" as any surgery that "...can be delayed for a minimum of three months without undue risk to the...health of the patient as determined by the...hospital, surgical center or other treating medical facility." On April 6, Governor Polis issued another executive order to extend the current order on elective surgeries to April 26.

The Colorado Ambulatory Surgery Center Association has been actively working with the Colorado Department of Public Health & Environment, the Colorado Hospital Association and the Governor’s staff to determine how ASCs can best support the continuum of healthcare in Colorado. Facilities in Colorado may contact Executive Director Chris Skagen with questions or ideas on how to best support the healthcare system in Colorado with the COVID-19 pandemic.

 

District of Columbia

On March 11 Mayor Muriel Bowser declared both a state of emergency and a public health emergency in Washington, DC in response to the COVID-19 outbreak. Following the recommendations from the US Surgeon General and the CDC, on March 17 DC Health issued recommendations on limitations of elective and non-urgent medical and dental procedures. The order states that, “in addition to halting all hospital elective procedures, the District of Columbia Department of Health (DC Health) is recommending that ALL elective medical procedures, non-urgent hospital and outpatient visits, and non-urgent dental procedures be postponed to preserve health care capacity as our community mitigation strategies work to flatten the epidemic curve.”

 

Florida

On March 1 Governor Ron DeSantis declared a public health emergency in the state. This was followed by another executive order on March 17 restricting access to bars and restaurants and requesting that people accessing Florida’s beaches abide by CDC guidelines. On March 16, CMS approved a 1135 Medicaid waiver filed by Florida. On March 20 Governor DeSantis issued an executive order directing that, “all hospitals, ambulatory surgical centers, office surgery centers, dental, orthodontic and endodontic offices, and other health care practitioners’ offices...are prohibited from providing any medically unnecessary, non-urgent or non-emergency procedure or surgery which, if delayed, does not place a patient’s immediate health, safety or wellbeing at risk, or will, if delayed, not contribute to the worsening of a serious or life-threatening medical condition. Accordingly, all health care practitioners...including dentists, shall immediately cease performing these elective services.” The order refers to recent guidance from CMS on elective procedures regarding examples of procedures to delay and permissible procedures.

Hawaii

On April 16, Governor Ige signed an executive order directing, “...all health care facilities, health care professionals, and health care volunteers...to render assistance in support of the State’s response to the disaster recognized by the Emergency Proclamations. For health care facilities, ‘rendering assistance’...includes cancelling or postponing elective surgeries and procedures as each facility determines to be appropriate under the circumstances presented by the COVID-19 emergency if elective surgeries or procedures are performed at the health care facility.” The order will remain in effect for the duration of the emergency period unless terminated by a separate proclamation.

Illinois

On March 9, Governor JB Pritzker signed a disaster proclamation for the coronavirus. On March 12, the state of Illinois and the city of Chicago released guidance on mandating all large-scale events over 1,000 people be cancelled or postponed until May 1. Events consisting of 250 people or more are encouraged to be cancelled or postponed until May 1. During a press briefing on March 14, Gov. Pritzker announced “with the federal government's newly declared state of emergency, under the Stafford Act my administration is filing a request for a federal waiver to allow our Medicaid program to more freely respond to the COVID-19 crisis by expanding medical services." On March 17, The Illinois Department of Public Health posted an elective surgical procedure guidance, “recommending cancelling ALL elective surgeries and procedures to immediately decompress the healthcare system during the COVID-19 response that are considered non-emergent or elective.” The guidance defines “elective” as, “those procedures that are pre-planned by both the patient and the physician that are advantageous to the patient but are NOT urgent or emergent.” On March 20 Governor Pritzker issued a stay at home order for state residents, directed non-essential businesses to cease operations and prohibited public gatherings. The order provides that healthcare and public health operations may continue and that individuals may leave the home to access such services: the order notes that, “healthcare and public health operations shall be construed broadly to avoid any impacts to the delivery of healthcare, broadly defined.”

 

Indiana

Governor Eric Holcomb declared a public health emergency for coronavirus on March 6. The state released a guidance document for gatherings on March 12: the document strongly recommends that for the next 30 days non-essential gatherings of 250 people or more should be postponed or canceled. On March 16 Governor Eric Holcomb announced additional steps to slow the spread of COVID-19 in Indiana. Among other directives, the Governor called on hospitals and ambulatory surgery centers to cancel and/or postpone elective and non-urgent surgical procedures immediately. He argued that “this action will help the healthcare system conserve resources and personnel necessary to meet emerging healthcare needs.” Later that same day Governor Holcomb issued an executive order directing, “hospitals and ambulatory surgical centers...to cancel or postpone elective and non-urgent surgical procedures immediately.” The order notes that, “physicians should continue to perform critical procedures necessary to prevent short-term or long-term adverse effects to their patients’ overall health.” On March 30 Governor Holcomb issued a new executive order containing provisions that supersede his order from March 16 regarding elective procedures. The order states that, “to preserve PPE for health care providers who are battling the COVID-19 pandemic, beginning April 1, 2020, all health care providers, whether medical, dental or other, and health care facilities, whether hospitals, ambulatory surgical centers, dental facilities, plastic surgery centers, dermatology offices and abortion clinics, are directed to cancel or postpone elective and non-urgent surgical or invasive procedures.” The order provides that “elective and non-urgent" procedures mean any surgery or invasive procedure which can be delayed without undue risk to the current or future health of the patient as determined by the treating provider. The order also notes that its provisions do not apply to any procedure that if performed in accordance with the commonly accepted standards of clinical practice, would not deplete the hospital capacity needed to cope with the COVID-19 outbreak.

 

Iowa

Governor Kim Reynolds signed a disaster proclamation on March 9 following confirmed coronavirus cases. The Department of Health announced on March 14 that large gatherings over 250 people should not be held. On March 17, Governor Reynolds issued a state of public health emergency, prohibiting any mass gatherings or events of over ten people until “the termination of this disaster.” Sections 8-11 of the document pertain to medical professions through the suspension of CON laws, loosening of telehealth rules, and the suspension of practicing with lapsed or inactive licenses within 5 years. On March 26 Governor Reynolds issued an additional disaster proclamation extending the business closure order and impacting the operation health care facilities. The order directs that effective at 5 p.m. on March 27 and until the disaster proclamation expires, “all nonessential or elective surgeries and procedures that utilize personal protective equipment (PPE) must not be conducted by any hospital, outpatient surgery provider, or outpatient procedure provider, whether public private or nonprofit.” The order provides that a nonessential surgery or procedures, “…is one that can be delayed without undue risk to the current or future health of a patient, considering all appropriate factors including, but not limited to any: (1) threat to the patient’s life if the surgery or procedure is not performed; (2) threat of permanent dysfunction of an extremity or organ system; (3) risk of metastasis or progression of staging; and (4) risk of rapidly worsening to severe symptoms.” The order directs hospitals and outpatient surgery and procedure providers to limit the use of PPE and requires such facilities to establish an internal governance structure to ensure adherence to the requirements of the order. On April 2 Governor Reynolds issued an updated proclamation of disaster emergency extending the expiration of the public health disaster emergency, including the previous order regarding elective procedures, to April 30. On April 9, the Department of Public Health issued a PPE Shortage Order, which states in part, “you shall immediately decrease demand for PPE by...comply(ing) with the ban on nonessential medical and dental services issued in the Proclamation of Disaster Emergency on March 26, 2020, and all subsequent extensions; cancel(ing) all other elective and non-urgent procedures and appointments which utilize PPE.”

 

Kentucky

Governor Andy Beshear declared a state of emergency on March 6. On March 11, Governor Beshear urged all individuals to minimize time in large gatherings and public spaces. On March 14, Governor Beshear held a briefing recommending that hospitals “soon cease elective procedures,” by Wednesday, March 18.  “We’re going to rely a lot on their judgment for what is elective,” said Governor Beshear. “We need all the capacity we can to deal with the cases that we believe we are going to see. We are going to work with them to give them the flexibility to repurpose a lot of their staff.” On March 18, the Kentucky Cabinet for Health and Family Services issued a directive stating that, “…healthcare providers in the Commonwealth are hereby directed…to cancel all procedures that in the opinion of a physician the delay will not cause harm to the patient or negatively affect the patient’s life expectancy. This directive takes effect at midnight March 18, 2020 and will include all levels of care.” On March 23 Governor Beshear issued his own order on the topic. Noting that previously the Governor had recommended that Kentucky hospitals cease performing elective procedures on March 18, the order directs that, “ALL non-emergent, non-urgent in-person medical, surgical, dental, and any other healthcare practice or procedure must have immediately ceased effective close of business on March 18, 2020.” The order provides that the state will rely on healthcare professionals to exercise their best clinical judgement in the implementation of the restriction and provides the following guidelines: “emergent” is any healthcare service that, were it not provided, is at high risk of resulting in serious and/or irreparable harm to a patient if not provided within 24 hours; “urgent” is any healthcare service that, were it not provided, is at high risk of resulting in serious and/or irreparable harm to a patient if not provided within 24 hours to 30 days; and “non-urgent” is any healthcare service that, were it not provided, is unlikely to result in any serious and/or irreparable harm to a patient if not provided for more than 30 days.

 

Louisiana

On March 11, Governor John Bel Edwards signed a public health emergency for coronavirus. Another proclamation on March 16 limited gatherings to fewer than 50 people following guidance from the CDC (from March 17 to April 13, 2020. On March 12, the Department of Health issued guidance recommending (among other things) that all facilities consider limiting or restricting all elective or voluntary medical procedures for the next 30 days. Following this guidance, the Louisiana Department of Health released a Healthcare Facility Notice March 18 stating, “…any and all medical and surgical procedures that…can be safely postponed for a period of thirty (30) days, SHALL be postponed for a period of thirty (30) days. This thirty (30) day period shall run from March 19, 2020, through April 21, 2020, unless otherwise extended in writing by the Department.” On March 21 the State Health Officer released a new Healthcare Facility Notice superseding the previous guidance on elective or voluntary surgeries. The new notice provides that, “...any and all medical and surgical procedures SHALL be postponed until further notice...”. Exceptions to the directive provide that medical and surgical procedures are allowed in order to treat an emergency medical condition as defined by 42 CFR 489.24. The notice additionally grants an exception to medical and surgical procedures necessary to avoid further harms from underlaying condition or disease. On March 24 the President of the Louisiana State Board of Medical Examiners released an open letter to licensees to revisit the order from the State Health Officer to halt elective procedures. “The LSMBE will have a zero tolerance policy of licensees violating these LDH, State Health Officer, orders. Complaints of violation of Dr. Guidy’s orders will be investigated an physicians will (be) subject to possible disciplinary action.” On April 7 the Louisiana Department of Health issued an emergency order extending a number of previously-issued orders until April 30: included in the list of orders is #2020-COVID-ALL-007, which is the healthcare facility notice issued on March 21 which directed the postponement of medical and surgical procedures in the state.

 

Maine

On March 15 Governor Janet Mills signed a civil emergency proclamation responding to the COVID-19 outbreak in Maine. While the proclamation itself is short and makes no mention of elective surgeries, Governor Mills recommended at the time of signing that, “all non-urgent medical procedures, elective surgeries, and appointments at hospitals and health care providers across the state…” be postponed until further notice. As part of this recommendation the Governor additionally recommended that events with 50 or more people be postponed.

 

Maryland

On March 5 Governor Larry Hogan issued a proclamation declaring a state of emergency. The Governor issued an executive order on public gatherings on March 12; on March 16 the order was updated to prohibit gatherings of more than 50 people. Governor Hogan issued an additional executive order on March 16 related to health care services: the order includes a provision authorizing the Secretary of Health to, “take actions to control, restrict, and regulate the use of health care facilities for the performance of elective medical procedures, as necessary to respond to the catastrophic health emergency.” On March 23 the Maryland Department of Health released a Directive and Order Regarding Various Healthcare Matters. The directive provides that, “pursuant to the Executive Order of March 16 relating to various health care matters...all licensed hospitals, ambulatory surgical centers, and all other licensed health care facilities shall cease all elective and non-urgent medical procedures effective at 5 p.m., Tuesday, March 24, 2020 and not provide any such procedures for the duration of the catastrophic health emergency.“

 

Massachusetts

Governor Charlie Baker declared a state of emergency on March 10. On March 15, the Governor issued an additional emergency order limiting gatherings to 25 individuals and prohibiting on-premises consumption of food or drink at bars and restaurants. Pursuant to the emergency powers authorized under the declaration, Public Health Commissioner Monica Bharel announced that effective from March 18, 2020, “until the State of Emergency is terminated by the Governor, or until rescinded by me, whichever shall happen first,” all hospitals and ambulatory surgery centers shall implement procedures issued by the Department of Public Health regarding the scheduling, cancelation and performance of non-essential elective invasive procedures. Additional guidance related to the order was released by the Department of Public Health the same day: the guidance recommends providers at hospitals and ASCs to use their clinical judgment on a case by case basis regarding any invasive procedures that must be done to preserve the patient’s life and health. Additionally, the guidance defines “nonessential, elective invasive procedures” to mean, “procedures that are scheduled in advance because the procedure does not involve a medical emergency…However, the ultimate decision is based on clinical judgment by the caring physician.”

 

Michigan

Governor Gretchen Whitmer declared a state of emergency in response to the COVID-19 outbreak on March 10. On March 16 the Governor issued a temporary prohibition lasting until April 5 on large assemblages and events over 50 people. The Governor also issued an executive order containing provisions intended to enhance the operational capacity of health care facilities in the state on March 17. On March 20, Governor Whitmer issued an executive order requiring “covered facilities” (defined to include freestanding surgical outpatient facilities) to implement a plan to temporarily postpone, until the termination of the state of emergency, all non-essential procedures. The order defines "non-essential procedures" as a medical or dental procedure that is not necessary to address a medical emergency or to preserve the health and safety of a patient, as determined by a licensed medical provider. The order is to take effect, “beginning as soon as possible but no later than March 21, 2020 at 5:00 pm, and continuing while the state of emergency...is in effect.”

 

Minnesota

Governor Tim Walz declared a peacetime emergency on March 13, urging the cancelation or postponement of gatherings greater than 250 people as well as social distancing of six feet. Governor Walz also urged limiting gatherings of 10 people or less with participants at high risk of illness. On March 19 Governor Walz signed an executive order directing the delay of inpatient and outpatient elective surgery and procedural cases during the COVID-19 peacetime emergency. The order directs that, “beginning no later than March 23, 2020 at 5:00 pm, and continuing for the duration of the peacetime emergency declaration…or until this Executive Order is rescinded, all non-essential or elective surgeries and procedures, including non-emergent or elective dental care, that utilize PPE or ventilators must be postponed indefinitely. The order defines as non-essential surgery or procedure as “…a surgery or procedure that can be delayed without undue risk to the current or future health of the patient,” and provides examples of criteria to consider in making this determination. The Minnesota executive order does not defer to the professional opinion of physicians to the same degree that orders in other states have, and it additionally includes a penalty of $1,000 fine or imprisonment for not more than 90 days for a person who willfully violates the order to indefinitely postpone such procedures.

 

Mississippi

Governor Tate Reeves issues a state of emergency proclamation on March 14 in response to the coronavirus outbreak. The state has not prohibited large gatherings, but the Department of Health has recommended people avoid large gathers of more than 250 people. Additionally, while no official announcement has been made, recent news reports suggest that during a press conference on March 16 with the Governor, the State Health Officer and the Director of Mississippi Emergency Management officials recommended that clinics cancel all unnecessary tests and elective surgery procedures should be delayed at hospitals and clinics. On March 19 the Mississippi Department of Health released an official Health Alert Network (HAN) Alert ordering the postponement of elective medical procedures and non-essential medical visits. The alert states, “physician, hospitals and medical centers must defer surgical and diagnostic procedures until COVID-19 spread has been diminished and the supply of protective medical equipment is restored.” The alert additionally states that, “patients should rescheduled any non-essential procedures, surgeries or medical visits until the threat of COVID-19 is diminished." On April 10 Governor Reeves issued an executive order directing that, “...all licensed health care professionals and all licensed health care facilities shall postpone all surgeries and procedures that are not immediately medically necessary to correct a serious medical condition of, or to preserve the life of, a patient who without immediate performance of the surgery or procedure would be at risk for serious adverse medical consequences or death, as determined by the patient’s physician.” The order provides an exception to any procedure that, if performed properly, would not have the potential to deplete, “...the hospital capacity, medical equipment or PPE needed to cope with the COVID-19 disaster.” The order will be in effect until April 27.

 

Nebraska

On March 13, Governor Pete Ricketts issued an emergency declaration in response to the coronavirus. The same day, the Department of Health and Human Services released guidance urging event organizers to limit public events to less than 250 people before community transmission, and drastically reducing that number to 20-50 people after community transmission began. On March 16, Governor Ricketts made two statements on public gatherings, first limiting all events to 50 people or less, then 10 as new guidance from the CDC was released. That same day, Governor Ricketts signed an executive order banning out of state travel for all executive branch state agencies. Governor Ricketts resisted issuing a statewide directed health measure ordering enforceable limits on public gatherings, the closure of bars and restaurants, the closure of schools and a prohibition on elective procedures, opting instead to issue directed health measures in a piecemeal fashion, targeting various counties at a time. However, on April 3 a statewide directed health order was issued that, among other things, prohibits elective medical and dental surgeries and elective medical and dental procedures. The order provides that “elective” means, “...a surgery or procedure that is scheduled in advance because it does not involve a medical or dental emergency,” and additionally provides that, “surgeries or procedures that must be done to preserve the patient’s life or physical health, but do not need to be performed immediately, are allowed by a case-by-case determination of the medical or dental provider.”

 

New Jersey

On February 3, Governor Phil Murphy created the Coronavirus Task Force, chaired by the Commissioner of the Department of Health to appropriately prepare for and respond to the “public health hazard caused by the virus.” The following month, on March 9 Governor Murphy declared a state of emergency. On March 16, another executive order was signed, limiting gatherings to 50 people or less (with a few noted exceptions including medical facilities). The order also closed facilities such as: casinos, racetracks, gyms, and entertainment centers. Failure to comply with the executive order may result in penalties. Governor Murphy also suggested a voluntary curfew of 8 p.m. On March 23 Governor Murphy issued an executive order directing, “beginning at 5:00 p.m. on Friday, March 27, 2020, all ‘elective’ surgeries performed on adults, whether medical or dental, and all ‘elective’ invasive procedures performed on adults, whether medical or dental, are suspended in the State.” The Governor’s order goes on to define “elective surgery or invasive procedure” as, “…any surgery or invasive procedure that can be delayed without undue risk to the current or future health of the patient as determined by the patient’s treating physician or dentist.” The order additionally directs ASCs to, “…coordinate any possible post-surgery admissions with local hospitals prior to performing any surgery or invasive procedure,” and requires both hospitals and ASCs to, “…establish written guidelines to ensure adherence to the provisions of this Order…”.

 

New Mexico

Governor Michelle Lujan Grisham declared a public health emergency on March 11 following the state’s first confirmed case of the coronavirus. At the time, the Governor and the Department of Health urged people to avoid “large public gatherings,” especially those of high risk. The following day, Health Secretary Kathy Kunkel issued an order prohibiting mass gatherings exceeding 100 people (with noted exceptions including health care facilities). Secretary Kunkel amended the order on March 15, requiring food and beverage establishments to operate at 50% capacity. On March 25 Governor Grisham announced the release of a new order from Secretary of Health Kunkel aimed at preserving PPE. The new order prohibits, “all hospitals and other health care facilities, ambulatory surgical facilities, dental, orthodontic and endodontic offices in the State of New Mexico…from providing non-essential health care services, procedures, and surgeries.” The order defines “non-essential health care services, procedures, and surgeries,” as those which can be delayed for three months without undue risk to patient health. The order also provides examples of criteria to consider when distinguishing between essential and non-essential actions and states that the prohibition on non-essential health care services, procedures and surgeries is not meant to apply to, “…(a) the provision of emergency medical care or any actions necessary to provide treatment to patients with emergency or urgent medical needs; (b) any surgery or treatment that if not performed would result in a serious condition of a patient worsening…and; (c) the full suite of family planning services.” The order takes effect March 27 and requires health care providers and facilities subject to the prohibition on non-essential procedures to submit a policy to the Department of Health addressing how it will comply with the order and identifying the procedures that will generally be deemed essential and non-essential. Providers and facilities will have until March 30 to submit their policy.

 

New York

New York Governor Andrew Cuomo declared a state of emergency due to the COVID-19 outbreak on March 7. In a follow-up declaration, the Governor banned events larger than 50 attendees until further notice and ordered bars and restaurants to cease dine-in operations, and gyms and movie theaters to cease operations, effective March 16. An additional declaration was issued focusing on the health care system in the state, though it did not contain provisions related to elective surgery. While the state government has not issued guidance regarding elective surgeries at this time, New York City Mayor Bill de Blasio issued an emergency executive order on March 16 directing hospitals and ASCs in the city to cancel or postpone elective procedures “within 96 hours of the issuance of this order”. Subsequent information suggests the exact timing of the start of the ban to be 4:00 p.m. on Friday, March 20. The emergency executive order directs hospitals and ASCs to “identify procedures that are deemed ‘elective’ by assessing which procedures can be postponed or cancelled based on patient risk considering the emergency need for redirection of resources to COVID-19 response.” On March 22, Governor Cuomo held a press conference during which he announced that, “we’re also canceling all elective, non-critical surgery for hospitals as of Wednesday. Elective, non-critical – the critical surgery, fine. If it’s not critical then postpone it.” On March 23 Governor Cuomo issued another executive order enacting many of the items he discussed during the March 22 press conference. In the order, the Commissioner of health is required to direct, “...all general hospitals, ambulatory surgery centers, office-based surgery practices and diagnostic and treatment centers to increase the number of beds available to patients, including by canceling all elective surgeries and procedures, as the Commissioner of Health shall define.”

 

North Carolina

Governor Roy Cooper declared a state of emergency on March 10. The Department of Health and Human Services released guidelines based off of the CDC’s recommendations to event organizers, including finding ways to limit close contact among people. DHHS released updated guidelines on March 12, recommending that mass gatherings of 100 people or more be canceled or postponed. On March 17 Governor Cooper issued an executive order to cease sit-down service at bars and restaurants, allowing them to stay open in a take-out and delivery capacity. On March 20 North Carolina Department of Health and Human Services Secretary Mandy Cohen released a letter to hospital and ASC leaders in the state requesting that they suspend elective and non-urgent procedures as of March 23. The letter defines such procedures as, “...any procedure or surgery that if not done within the next 4 weeks would cause harm to the patient.” The letter also stated that beginning March 20, “...hospitals and ambulatory surgery centers should institute an explicit, real-time review of all non-time sensitive procedures and surgeries.

 

Ohio

Governor Mike DeWine declared a state of emergency on March 9. On March 12, Ohio Department of Health Director Amy Acton signed an order prohibiting gatherings of 100 or more people; that number was reduced to 50 people on March 16. During a press conference on March 14, Governor DeWine announced that his health advisory group is in the process of developing guidelines for doctors for postponing elective surgeries that will not put patients at risks. On March 17, the Department of Health issued an order for the management of non-essential surgeries and procedures: the directive ordered that, effective 5:00 p.m. March 18, all non-essential or elective surgeries and procedures utilizing PPE not be conducted. The order will remain in force for the length of the state of emergency or until lifted by the Department of Health. The order describes a non-essential surgery as, “a procedure that can be delayed without undue risk to the current or future health of a patient,” provides examples of criteria to be considered and directs, “each hospital and outpatient surgery or procedure provider, whether public, private, or nonprofit, shall establish an internal governance structure to ensure the principles outlined…are followed.” On March 22 Department of Health Director Amy Acton signed a stay at home order ordering state residents to stay at home, non-essential businesses to cease operations, prohibiting public gatherings and asking that people limit travel. The order provides that healthcare and public health operations may continue and that individuals may leave the home to access such services: the order notes that, “healthcare and public health operations shall be construed broadly to avoid any impacts to the delivery of healthcare, broadly defined.”

 

Oklahoma

On March 15, Governor Kevin Stitt declared a state of emergency due to the coronavirus. An amended executive order was signed on March 17, requiring all “hospitals, medical clinics, and private testing labs to report accurate data to the state health department every day regarding their capacity to accept new patients, their equipment supplies, and their testing results.” The order also grants out of state medical professionals license to practice in Oklahoma (as long as their out of state license is issued by an accredited Board). All occupational licenses set to expire during the emergency are also extended until two weeks following the termination of the emergency.

A second executive order was issued on March 17, giving guidance for the next 15 days. Recommendations include avoiding social gatherings of more than 10 people and avoiding eating in restaurants and bars. On March 24 Governor Stitt issued a new executive order expanding on his previous orders. The order directs that, “Oklahomans and medical providers in Oklahoma shall postpone all elective surgeries, minor medical procedures, and non-emergency dental procedures until April 7, 2020.” The order additionally requires hospitals and physician clinics in the state to make a daily submission of the following critical data to the state Department of Health: number of available ICU beds, medical surgery beds, operating room beds, pediatric beds, PICU beds, ventilators, negative flow rooms and overall occupancy status; COVID-19 test availability; the number of positive patients and persons under investigation, both in the facility and that have been sent home to self-quarantine; and days of essential PPE stock on hand, as measured by the facility’s defined daily adjusted burn rate of PPE. On April 1 Governor Stitt issued another executive order extending the required postponement of all elective surgeries, minor medical procedures and non-emergency dental procedures until April 30. The order additionally requires hospitals and physician clinics in the state to submit a daily report to the Department of Health covering: the number of available ICU beds, medical surgery beds, operating room beds, pediatric beds, PICU beds, ventilators, anesthesia machines capable of patient ventilation, ventilator connecting circuits, patient interfaces, negative flow rooms and overall occupancy status; COVID-19 test availability; the number of positive patients and persons under investigation in the hospital receiving treatment and positive patients and persons under investigation sent home for self-quarantine; personal protective equipment (PPE) stock on hand.

On April 15, Governor Stitt issued an amended executive order, extending the state’s “Safer at Home” order to May 6 and allowing elective surgeries to resume in the state starting on April 24. The order provides that, “Oklahomans and medical providers shall postpone all elective surgeries until April 24th, 2020. Elective procedures after April 24th, 2020 are subject to the guidelines set forth in Executive Memo 2020-02.” The order also directs providers to the CMS Non-Emergent, Elective Medical Services, and Treatment Recommendations when determining what is considered an elective surgery.

 

Oregon

On March 8 Governor Kate Brown issued a declaration of emergency due to Coronavirus (COVID-19) Outbreak in Oregon. On March 12 Governor Brown issued an executive order prohibiting large gatherings due to Coronavirus (COVID-19) Outbreak in Oregon, as well as announced the closure of K-12 Oregon schools from March 16 to March 31. On March 17 Governor Brown issued an executive order prohibiting on-premises consumption of food or drink and gatherings of more than 25 People.

On March 18, Governor Brown directed all hospitals, outpatient clinics and health care providers to, “cease all non-emergency procedures, in order to preserve personal protective equipment…for health care workers treating COVID-19 patients.” to preserve masks, medical supplies.

The Oregon Ambulatory Surgery Center Association has been actively working with the Oregon Health Authority, the Oregon Association of Hospitals and Hospital Systems and the Governor’s staff to determine how ASCs can best support the continuum of healthcare in Oregon. Facilities in Oregon may contact Executive Director Chris Skagen at cskagen@ascoregon.org with questions or ideas on how to best support the healthcare system in Oregon with the COVID-19 pandemic.

 

Pennsylvania

On March 6 Governor Tom Wolf proclaimed a state of emergency in the state. On March 15 all restaurants and bars were ordered to close their dine-in facilities in Allegheny, Bucks, Chester, Delaware and Montgomery Counties; the administration additionally “strongly urged non-essential businesses in the four counties [Bucks, Chester, Delaware and Montgomery] to close during their county-specific mitigation periods to protect employees, customers, and suppliers and limit the spread of the virus through personal contact and surfaces.” On March 17 news reports suggested that a spokesperson for the Department of Health had said that hospitals, “should review all scheduled elective admissions, surgeries and procedures and develop a plan to postpone or cancel those admissions, surgeries and procedures if they have not done so already.” On March 18 the Pennsylvania Secretary of Health, Dr. Rachel Levine, said people should consider canceling elective surgeries. “People need to talk to their doctor about that…Elective could mean different things to different people, but the overall answer is yes. If something needs to be done to protect someone’s health, that procedure should be done, but it’s very important that hospital and health systems prepare for the expected surge of patients, particularly ill patients, requiring in-patient admission that could very likely occur over next several weeks.”

On March 19 Governor Wolf issued a new order prohibiting the operation of all businesses that are not life sustaining businesses: this was accompanied by a similar order from the Secretary of Health and a list detailing which businesses in the state are considered life sustaining. The list provides that hospitals and ambulatory health care services may continue physical operations elective procedures are prohibited. On April 1 the Department of Health issued an amended order requiring ASCs to complete the Ambulatory Surgical Facilities Survey on a daily basis for each day a center is operational. The amended order takes effect immediately. On the same day the Department released amended guidance to reflect the new order. This updated guidance provides that, following the original effective date of March 20, ASCs, “...may not perform any elective surgeries or procedures unless the surgery or procedure would preserve an organ function or avoid further harms from an underlying condition or disease.” The update also prohibits ASCs from allowing the performance of, “...surgeries to treat emergency or life-threatening conditions to occur in the facility, unless no hospital is available for the procedure and the need for the surgery could not have been anticipated.” Lastly, the updated guidance incorporates the requirement that all ASCs complete the Ambulatory Surgical Facilities Survey on a daily basis.

 

South Carolina

On March 11 Governor Henry McMaster issued a state of emergency for South Carolina; he expanded the declaration on March 13. On March 15 the Governor issued an additional executive order that included a recommendation that indoor and outdoor public gatherings be canceled, postponed or rescheduled or limited so as not to exceed 100 people. On March 17 news reports from multiple sources on indicated that Governor McMaster had issued a number of additional orders that prohibited public events of over 50 people and required the closing of bars and restaurants. Reports suggest that the orders include a recommendation (not an order) that medical and surgical centers in the state halt all elective surgeries in the next 72 hours. On the evening of March 17 the Governor signed a new executive order containing a prohibition on large public gatherings, a restriction on restaurant and bar service and provisions allowing coordination between the national guard and health providers in the state. No provisions in the order addressed elective surgeries, and no other official orders on the matter have been posted on the Governor’s or Department of Health’s websites at this time.

 

South Dakota

Governor Kristi Noem declared a state of emergency on March 13 in response to the coronavirus. Following this declaration, Governor Noem released an additional executive order on March 23 related large public gatherings and the operation of businesses and health care organizations in the state. Included in the order is a directive that health care organizations should, “postpone all non-essential elective surgeries to conserve (and thereby maximize) supplies of personal protective equipment.” The order expires on May 2, 2020. On April 6 Governor Noem issued an updated executive order, directing that all health care organizations in the state shall, “postpone all non-essential surgeries to conserve (and thereby maximize) supplies of personal protective equipment (PPE).” The order will expire on May 31.

 

Tennessee

On March 12 Governor Bill Lee signed an executive order declaring a state of emergency in response to the COVID-19 outbreak. Governor Lee issued guidance on March 13 regarding mass gatherings, strongly discouraging events of 250 people or more. While neither the Governor nor the Department of Health have released a mandate or guidance targeted at elective surgeries, the Department of Health has released guidance for health care providers on PPE conservation which includes a recommendation that providers, “consider delaying or rescheduling elective visits, admissions, surgeries and procedures.” On March 23, Governor Bill Lee signed a new executive order stating that, “all hospitals and surgical outpatient facilities in the State of Tennessee shall not perform non-essential procedures, which includes any medical procedure that is not necessary to address a medical emergency or to preserve the health and safety of a patient, as determined by a licensed medical provider. All hospitals and freestanding surgical outpatient facilities must postpone through the expiration of this Order, at a minimum, joint replacement, bariatric surgery, and cosmetic surgery, except for emergency or trauma-related surgery where postponement would significantly impact the health, safety, or welfare of the patient.” The order excludes a number of procedures from postponement: surgeries related to advanced cardiovascular disease that would prolong life; oncological testing, treatment and related procedures; pregnancy-related visits and procedures, including labor and delivery; organ transplantation; procedures relating to dialysis; and emergency or trauma-related procedures where postponement would significantly impact the health, safety and welfare of the patient. The order takes effect at 12:01 a.m. on March 24 and shall remain in effect until April 13.

On April 8 Governor Lee issued a new executive order related to elective surgeries. Beginning on April 9, “all healthcare professionals and healthcare facilities in the State of Tennessee shall postpone surgical and invasive procedures that are elective and non-urgent. Elective and non-urgent procedures are those that can be delayed until the expiration of this Order because they are not required to provide life-sustaining treatment, to prevent death or risk of substantial impairment of a major bodily function, or to prevent rapid deterioration or serious adverse consequences to a patient’s physical condition if the surgical or invasive procedure is not performed, as reasonably determined by a licensed medical provider.” The order will remain in effect until April 30.

 

Texas

Governor Greg Abbott declared a state of disaster on March 13. The following day, Governor Abbott directed the Texas Medical Board (TMB) and the Texas Board of Nursing (TBN) to, “fast-track the temporary licensing of out-of-state physicians, physician assistants, certain retired physicians, nurses, and other license types,” to assist in Texas' response to COVID-19. Additionally, TMB encouraged retired physicians who are Texas residents with licenses that have been placed on official retired status for less than two years to apply for a return to active status. On March 19 the Governor issued an executive order limiting public gatherings in line with the CDC’s recommendations. On March 22 Governor Abbott released an additional executive order directing, “…all licensed health care professionals and all licensed health care facilities shall postpone all surgeries and procedures that are not immediately medically necessary to correct a serious medical condition of, or to preserve the life of, a patient who without immediate performance of the surgery or procedure would be at risk for serious adverse medical consequences or death, as determined by the patient’s physician.” The order remains in effect until April 21. On March 24 the Texas Medical Board issued a press release announcing the passage of emergency rules to enforce the Governor’s executive order regarding elective procedures. The emergency rules amend the definition of “continuing threat to the public welfare” under the code pertaining to Temporary Suspension and Restriction Proceedings to include actions specifically prohibited by the Governor’s executive order and requires immediate reporting under the peer review law of any physician, “...scheduling to perform, preparing to perform, performing, or who has performed a non-urgent elective surgery or procedure...while Executive Order GA 089 is in effect...”.

On April 17, Governor Abbott issued a new executive order loosening the restrictions imposed on elective surgeries in March. Beginning at 11:59 pm on April 21 and continuing until 11:59 pm on May 8, the order requires that all licensed health care professionals and facilities continue postponing all surgeries and procedures that are not medically necessary. However, the order provides an exemption from the prohibition for: any procedure that would not deplete the hospital capacity or the PPE needed to cope with the COVID-19 disaster; or any surgery or procedure performed in a licensed facility that has certified in writing to the Texas Health and Human Services Commission both, “...(1) that it will reserve at least 25% of its hospital capacity for treatment of COVID-19 patients, accounting for the range of clinical severity of COVID-l9 patients; and (2) that it will not request any personal protective equipment from any public source, whether federal, state, or local, for the duration of the COVID 19 disaster.”

 

Utah

Governor Gary Herbert declared an anticipatory state of emergency on March 6. On March 12, Governor Herbert introduced measures to help slow the spread of the coronavirus, such as limiting the number of people in a mass gathering to 100; the Governor also recommended that people over the age of 60 and individuals who are immunocompromised should refrain from groups over 20. In coordination with the Governor’s Office, the Department of Health and the Utah COVID-19 Community Task Force, an order was issued to suspend all dine-in operations at food establishments for a period of two weeks. On March 24 Executive Director of the Department of Health Joseph Miner released a State Public Health Order directing that, “…effective as of 12:01 a.m. on March 25, 2020, all licensed health-care professionals and all licensed health-care facilities shall postpone all elective surgeries and procedures in accordance with version 3.15.20 of the CMS Adult Elective Surgery and Procedures Recommendations, promulgated by the Centers for Medicare & Medicaid Services on March 18, 2020.” The order remains in effect until 11:59 p.m. on April 25, unless otherwise modified, amended, rescinded or superseded.

 

Vermont

On March 13, Governor Phil Scott declared a state of emergency in response to the spread of the coronavirus. In this order, Gov. Scott prohibited “non-essential” gatherings of more than 250 people in a single room. On March 16, Governor Scott introduced guidance to restrict mass gatherings to 50 people or 50% of the capacity of a facility. The closure of all bars and restaurants was also ordered, but these establishments can still operate through takeout or delivery. These measures are in effect until April 6, unless otherwise noted. Governor Scott issued an addendum to his state of emergency declaration on March 20 related to the provision of medical care during the outbreak. Governor Scott orders, “…all clinicians in Vermont to expedite postponement of all non-essential adult elective surgery and medical and surgical procedures, including all dental procedures in the safest but most expedient way possible.” The order goes on to note that, “while case-by-case evaluations will be made by clinicians, the following factors are to be considered as to whether planned surgery should proceed: current and projected COVID-19 cases in the facility and region; supply of PPE to the facilities in the system; staffing availability; bed availability, especially intensive care unit (ICU) beds; ventilator ability; health and age of the patient, especially given the risks of concurrent COVID-19 infection during recovery; (and) urgency of the procedure.” The order will remain in effect until April 15. On April 10, Governor Scott issued addendum nine to his initial executive order declaring a state of emergency, extending all directives contained in previous orders and addendums (including those directives related to elective surgeries) until May 15.

 

Virginia

On March 12, Governor Ralph Northam declared a state of emergency in response to the spread of the coronavirus. In the press release, Gov. Northam noted the Commonwealth of Virginia would cancel “all specially-scheduled state conferences and large events for a minimum of 30 days.” The Governor also urged the limitation of public events, effective immediately. On March 17, the Governor and Health Commissioner issued a public health emergency limiting the number of patrons allowed in restaurants, fitness centers, and theaters to 10. On March 25 Governor Northam released another executive order, “…prohibiting all inpatient and outpatient surgical hospitals…free-standing endoscopy centers, physicians’ offices, and dental, orthodontic, and endodontic offices in the Commonwealth from providing procedures and surgeries that require PPE, which if delayed, are not anticipated to cause harm to the patient by negatively affecting the patient’s health outcomes, or leading to disability or death.” The order provides that inpatient and outpatient surgical facilities, free-standing endoscopy centers, physicians’ offices, and dental, orthodontic, and endodontic offices may perform any procedure or surgery that if delayed or canceled would result in the patient’s condition worsening, and encourages outpatient surgical hospitals to work with their local inpatient hospitals to assist with surge capacity needs. The order shall remain in force until April 24.

 

Washington

On February 29 Governor Jay Inslee issued an emergency proclamation declaring a state of emergency in response to the COVID-19 outbreak in the state. On March 16 the Governor issued an additional emergency proclamation prohibiting large gatherings in public venues, prohibiting the onsite consumption of food and or beverages in a public venue and prohibiting the operation of all retail stores “unless they designate an employee or officer who must establish and implement social distancing and sanitation measures…”. While the Governor has not made an official proclamation on the subject, during an interview with Rachel Maddow on March 16 he noted the state efforts to increase its medical capacity and reiterated that the state, “might soon have some difficult choice to free up hospital capacity by possibly postponing elective surgeries, keeping large gatherings to a minimum and more.” On March 19 Governor Inslee issued a proclamation to, “...prohibit all hospitals, ambulatory surgical facilities, dental, orthodontic and endodontic offices in Washington State from providing health care services, procedures, and surgeries that, if delayed, are not anticipated to cause harm to the patient within the next three months...this does not include outpatient visits delivered in hospital based clinics.” The Governor’s proclamation includes examples of procedures to delay and also provides an exception from the prohibition for, “the full suite of family planning services and procedures...(and) treatment for patients with emergency/urgent needs...Hospitals and ambulatory surgical facilities may perform any surgery that if delayed or canceled would result in the patient’s condition worsening...”.

 

West Virginia

Governor Jim Justice declared a state of emergency on March 16 in response to the national emergency declared by President Donald Trump. Governor Justice urged citizens to follow the guidelines set out limiting social gatherings to groups of 10. Following the state’s first confirmed case on March 17, Governor Justice ordered the closure of bars, restaurants, and casinos (however, food establishment can continue carry out and drive-thru operations). On March 31 Governor Justice issued an executive order prohibiting all elective medical procedures, “…provided that patients will still have access to urgent, medically necessary procedures like those needed to preserve the patient’s life or long-term health; and provided that this prohibition applies equally to all types of elective medical procedures performed in hospitals, offices, and clinics throughout the state.” The order provides that “elective” includes, “…medical procedures that are not immediately necessary to preserve the patient’s life or long-term health, except that procedures that cannot be postponed without compromising the patient’s long-term health, procedures that cannot be performed consistent with other law at a later date, or procedures that are religiously mandated shall not be considered ‘elective’ under this Order.” The order takes effect at 12:00 a.m. on April 1; the order does not include a repeal date.