Across the U.S., state governors have issued numerous orders in their efforts to slow the spread of the novel coronavirus (COVID-19), with the most important falling into two categories: “stay-at-home” (or “shelter-in-place”) directives; and orders prohibiting elective procedures.

Stay-at-Home. These directives are mostly similar in nature across the states, specifying activities that are prohibited and “essential activities” that are allowed while the order is in place. Similarly, the orders identify “non-essential” businesses that must be closed during the order and “essential businesses” that may remain open. All states that have issued these orders have characterized health care as an “essential business” or “essential activity” and allowed for continued in-person operations. Many mayors have issued similar edicts, however, this alert focuses solely on the state level.

Elective Procedure Orders. These are also very similar from state-to-state and generally require the cancellation or postponement of surgeries and invasive procedures, except in cases involving life-sustaining treatment, threats to loss of bodily or organ function, or where there is a risk of undue harm to the patient from not performing a procedure. Some states are also asking or requiring providers to consider other factors when determining whether a procedure is elective, including: the recent Centers for Medicare & Medicaid Services (CMS recommendations on postponing adult non-essential medical, surgical and dental procedures; the capacity of the health care system based on the number of available hospital beds, the supply of necessary medical equipment and supplies such as person protective equipment (PPE and ventilators, and staffing availability; and potential post-operative complications and the potential need to transfer a patient from an ambulatory surgery center (ASC to a hospital. We provided information on the CMS recommendations in a March 20 alert, but as the COVID-19 situation has evolved, states have issued more aggressive orders prohibiting elective procedures whereas the CMS recommendations are currently nonbinding.

Impact on Healthcare Providers. Ultimately, whether a procedure is elective is a clinical judgment that must be determined based on the facts and circumstances of each patient’s condition and the capacity of the health care system at that time. However, in making these judgments, healthcare providers must take into account any specific factors noted in the applicable state orders prohibiting elective procedures. Further, healthcare providers should ensure they appropriately document that these factors have been taken into consideration when determining which procedures are elective and should be postponed and which procedures are not elective and should go forward.

To date, neither the CMS nor the Centers for Disease Control and Prevention (CDC) nor any state have required that providers retain any specific documentation. However, providers should ensure that they maintain proper documentation of the risk analysis performed in determining to go forward with a procedure or surgery, including considering the impact on availability of critical resources for other procedures and the applicable state factors. McGuireWoods has developed and is continuing to develop forms for this purpose and we are happy to address questions and needs on these and related topics in this ever-changing climate.

Individual State Orders. We have prepared a succinct state-by-state summary and color-coded map of individual directives and orders that impact healthcare providers and elective procedures. Please click below to expand to view any orders and directives that are applicable to your state. This information is recent as of 12 a.m. ET on March 26, 2020, and will be updated regularly.

General Guidance

A decision whether a procedure or surgery is elective or should be postponed or canceled under any state directive to do so is a clinical determination that each provider and facility must determine based on the risks and benefits of each case.

In determining whether to proceed with a procedure, providers must take care to heed any executive orders from their states, local governments, or other directives from agencies such as a Department of Health and should consult and consider the CDC and CMS guidelines.

As noted above, while no state nor CMS nor the CDC appears to have yet indicated any specific documentation that must be maintained (recognizing that in all matters related to COVID-19, the situation is fluid and ever-changing), we recommend that providers ensure they maintain proper documentation of the risk analysis performed in determining to forward with a procedure or surgery. McGuireWoods stands ready to assist and has developed and is continuing to develop forms for such purposes.

Alabama

Stay-at-Home. On March 19, 2020, the Alabama State Health Officer issued an order directing the closure of many non-essential businesses as well as putting in place parameters for the continued operation of certain businesses. The order does not affect healthcare providers and facilities.

Elective Procedures. The March 19 order also notes that as of the date of the order, all elective and dental medical procedures shall be delayed. The order does not provide any additional guidance on what constitutes an elective procedure. Therefore, we recommend providers continue to utilize the CMS guidelines.

Alaska

Stay-at-Home. Alaska does not appear to have issued a stay-at-home order.

Elective Procedures. While Gov. Mike Dunleavy issued Health Mandates 006 and 007 on March 19, 2020, requiring the postponement of all elective dental procedures for a period of one month and the postponement or cancellation of all elective or non-urgent medical procedures for a period of three months. Regarding dental procedures, the mandate recommends the following actions:

1. Prioritize treatment for patients experiencing dental emergencies, defined by the ADA as “Health care related to relief of severe dental/oral pain and infection management.”
2. To help decrease the overburden on emergency rooms and urgent care facilities as the COVID-19 response rapidly increases, oral health practitioners are encouraged to provide emergency dental care through patients’ regular dental home, including after-hours where possible, except in the case of a life-threatening emergency.
3. Limit orders and use of PPE to the minimum necessary for emergency care.

Regarding medical procedures, elective and non-urgent medical procedures include pre-scheduled surgeries that are deemed non-essential but does not apply to surgical cases coming through the emergency room or to existing hospitalized patients. Further, the mandate notes that the terms “non-urgent or elective” are not specifically defined and recommends that hospitals create a physician task force to be available to make determinations on a case-by-case basis.

Arizona

Stay-at-Home. Arizona does not appear to have issued a stay-at-home order.

Elective Procedures. Gov. Doug Ducey issued Executive Order 2020-10, effective March 21, 2020, ordering that all non-essential or elective surgeries (including elective dental surgeries) that utilize PPE or ventilators not be performed at any state licensed healthcare facility or by any state licensed healthcare provider. A “non-essential or elective surgery” is defined as “a surgery that can be delayed without undue risk to the current or future health of a patient.” Healthcare providers are to use their best medical judgment to determine whether a procedure is elective or not and in making that decision, must consider the health and age of the patient, especially in light of the COVID-19 infection and effects on recovery and the urgency of the surgery. Further, the order provides that a procedure should not be deemed elective “if it would threaten the patient’s life, threaten permanent dysfunction or impairment of any body part, risk metastasis or progression of staging, or require the patient to remain hospitalized if the surgery was delayed.”

California

Stay-at-Home. Effective from March 19, 2020, Gov. Gavin Newsome issued California Executive Order N-33-20, directing that all individuals stay at home except as needed to maintain critical infrastructure sectors. Such critical infrastructure sectors include healthcare and public health which is defined broadly as healthcare facilities, research centers, suppliers, manufacturers, and other physical assets and vast, complex public-private information technology systems required for care delivery and to support the rapid, secure transmission and storage of large amounts of healthcare data. Essential workforce members therefore include healthcare providers and caregivers.

Elective Procedures. The March 19 Executive Order also provides that the healthcare delivery system shall prioritize services to those who are sickest and shall prioritize resources, including PPE, for the providers providing direct care. While the order does not prohibit elective procedures, and California does not yet appear to have issued a specific order regarding elective procedures, the California Department of Public Health has noted on under Frequently Asked Questions that “non-essential medical care like eye exams, teeth cleaning, and elective procedures must/should be canceled or rescheduled. If possible, health care visits should be done remotely.” California does not yet appear to have issued any more formal guidance on criteria to consider whether a procedure is non-essential, but, as noted, the situation is rapidly changing.

Colorado

Stay-at-Home. Colorado does not appear to have issued a statewide stay-at-home order, although Denver and Boulder have issued such orders.

Elective Procedures. Gov. Jared Polis issued Executive Order D 2020 009, effective March 23, 2020 through April 14, 2020, ordering that all hospitals and outpatient surgery and procedure providers cease all elective and non-essential surgeries and procedures. The order also directs all such providers to preserve PPE, ventilators, and respirators. Rural and critical access hospitals are exempted from the order, but are strongly advised to follow its directives. The order applies to all dental, medical, and veterinary “voluntary or elective procedures,” which is defined as surgeries or procedures that “can be delayed for a minimum of three months without undue risk to the current or future health of the patient as determined by the guidelines developed by the hospital, surgical center or other treating medical facility.” The order also notes that surgeries and procedures can continue for the following:

1. There is a threat to the patient’s life if the surgery or procedure is not performed;
2. There is a threat of permanent dysfunction of an extremity or organ system if the surgery or procedure is not performed;
3. There is a risk of metastasis or progression of staging of a disease or condition if the surgery or procedure is not performed; or
4. There is a risk that the patient's condition will rapidly deteriorate if the surgery or procedure is not performed and there is a threat to life, or to an extremity or organ system, or of permanent dysfunction or disability.

Further, the order provides that only essential personnel for a surgery or procedure shall be in the procedure room where PPE is required in order to preserve PPE. Hospitals and ASCs are also ordered to develop guidelines based on the above principles and must include a process for consultation with the treating provider regarding designating procedures as elective or non-essential.

Connecticut

Stay-at-Home. Gov. Ned Lamont issued Executive Order No. 7H, effective as of March 23, 2020 through April 22, 2020, directing all non-essential functions in Connecticut to suspend in-person operations. Essential businesses and functions include essential healthcare operations such as hospitals, clinics, dentists, pharmacies, elder care and home health care workers, companies and institutions involved in the research and development, manufacture, distribution, warehousing, and supplying of pharmaceuticals, biotechnology therapies, health care data, consumer health products, medical devices, diagnostics, equipment, services and any other healthcare related supplies or services.

Elective Procedures. Connecticut does not appear to have issued a specific order addressing prohibitions on elective procedures.

Delaware

Stay-at-Home. Effective March 24, 2020, Gov. John Carney of Delaware issued the fifth modification to the Delaware State of Emergency order, which was issued on March 12, 2020. Similar to other states, the Delaware order prohibits residents from leaving their current residences, unless it is for an essential activity. Essential activities include the provision of healthcare services.

Elective Procedures. Delaware does not appear to have issued an order regarding elective procedures.

Florida

Stay-at-Home. Florida does not appear to have issued a stay-at-home order.

Elective Procedures. Gov. Ron DeSantis issued Executive Order No. 20-72, effective March 20, 2020, prohibiting all hospitals, ASCs, office surgery centers, dental, orthodontic and endodontic offices, and other health care practitioners’ offices “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 well-being at risk, or will, if delayed, not contribute to the worsening of a serious or life-threatening medical condition.” The order also states that, as noted in the CMS recommendations, examples of procedures to delay include some endoscopy, most cataract and lens surgeries, non-urgent spine and orthopedic procedures, and cosmetic procedures. Further, the directive also cites the CMS examples of permissible procedures that can be performed, such as removal of a cancerous tumors, transplants, limb-threatening vascular surgeries, trauma-related procedures, and dental care related to the relief of pain and management of infection.

Hawaii

Stay-at-Home. Effective March 25, 2020, through April 30, 3030, Hawaii Gov. David Y. Ige issued the Third Supplementary Proclamation for COVID-19. As with other states, the order prohibits individuals from leaving their homes, unless it is for an essential activity. Essential activities include healthcare services. The Hawaii order also requires essential businesses to exercise certain requirements, such as having separate operating hours for elderly and high-risk customers and posting online whether a facility is open and how to reach the facility and continue services by phone.

Elective Procedures. Hawaii does not appear to have issued an order regarding elective procedures.

Illinois

Stay-at-Home. Effective March 21, 2020 at 5 p.m. through April 7, 2020, Gov. J.B. Pritzker issued a “stay-at-home” order (COVID-19 Executive Order No. 8) in response to the spread of COVID-19 in Illinois. Healthcare and public health operations listed in the Illinois order include examples such as biotechnology companies, medical cannabis dispensaries, reproductive health care providers, mental and substance abuse providers, and generally healthcare facilities, providers, and suppliers of healthcare services.

Elective Procedures. The Illinois Department of Public Health (IDPH) issued guidance regarding elective surgical procedures, which recommends cancelling all elective surgeries and procedures. Elective is defined 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. Physicians should use their medical judgement to determine the need for surgery.” The IDPH guidance also urges providers to consider other factors to ensure that the adequacy of healthcare providers, supplies, space, considering the spread and potential surge of COVID-19 such as:

1. Staffing Considerations
   1. Continue to account for staffing necessary to perform emergent operations or procedures.
   2. Canceling elective procedures to free up nurses, doctors, surgeons, and anesthesia providers to provide care for patients when the system becomes overwhelmed.
   3. Hospitals should set up alternate staffing plans to accommodate the influx of patients.
   4. Examine utilizing nurse Anesthetists, pre-/post-operative nurses, and nurse practitioners to provide alternative levels of care elsewhere.
   5. Use administrative/clerical staff to possibly set up childcare areas for essential medical staff to continue to work if daycares are closed.
   6. Hospitals should assess how to provide just in time training to those staff that could fulfill other roles in a patient care/assistive capacity.
2. Space Considerations
   1. The pre-anesthesia and recovery rooms can then be used for patient care.
   2. Outpatient surgery centers affiliated with hospitals could be used for overflow or redirecting of less sick patients in an alternate treatment area and staff could be used there.
   3. Supplies/resource considerations
   4. Canceling procedures will also allow for reallocation of PPE that is used for surgical procedures.
   5. Beds, stretchers, and linens can be used for inpatient care instead of surgical procedures.
   6. Ventilators could be reallocated from surgical areas to patient care areas.

Indiana

Stay-at-Home. Indiana Gov. Eric J. Holcomb issued Executive Order No. 8, effective March 24, 2020 through April 6, 2020, ordering that all people stay at home unless engaging in essential activities or essential businesses and operations, which are defined as including travel for health and safety. The order also provides that individuals may leave their residences to engage in healthcare and public health operations, which is broadly defined and includes hospitals, clinics, dental offices, pharmacies, public health entities, pharmaceutical and medical device companies, OBGYNs, eye care centers, home health, mental health and substance abuse, veterinary care, amongst others.

Elective procedures. While Indiana does not appear to have issued an executive order regarding elective procedures, Gov. Holcomb announced, on March 16, 2020, a series of additional measures to slow the spread of COVID-19, which included a measure noting that hospitals and ASCs should cancel and/or postpone elective and non-urgent surgical procedures immediately. The announcement also noted that providers may continue to perform “critical procedures necessary to prevent short-term and/or long-term adverse effects to their patients’ overall health.”

Kentucky

Stay-at-Home. Kentucky does not appear to have issued a stay-at-home order.

Elective Procedures. On March 18, 2020, the Kentucky Cabinet for Health and Family Services issued a directive “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.” The directive did not provide any further guidance on factors to consider or measure to take.

Louisiana

Stay-at-Home. Gov. John Bel Edwards issued Proclamation No. 33 JBE 2020, effective March 23, 2020, wherein all residents were ordered to stay-at-home unless performing an essential activity. Such essential activities include going to and from work for essential worker functions, which includes the provision of healthcare.

Elective Procedures. Effective March 21, 2020, the Louisiana Department of Health updated its prior guidance and issued an additional order that all medical and surgical procedures, other than those specifically listed as exceptions, be postponed. Surgeries and procedures to treat emergency medical conditions, as defined by EMTALA, are exceptions to this rule and may be performed. Further, medical and surgical procedures are also allowed to avoid further harms from an underlying condition or disease. The department also noted that providers should transition to telehealth, when appropriate, and postpone all in-person services that can be safely postponed for 30 days.

Maine

Stay-at-Home. Gov. Janet Mills issued Executive Order No. 19 FY 19/20 on March 25, 2020 through April 8, 2020, ordering Maine residents to stay at home and close all non-essential businesses. The order references past guidance from the Main Center for Disease Control and Prevention.

Elective Procedures. Following the Gov. Mills’ State of Emergency Proclamation, and per Maine Center for Disease Control and Prevention’s guidance issued on March 15, 2020, non-urgent medical and dental procedures, elective surgeries, and appointments should be postponed based on consultations between individuals and providers until further notice.

Maryland

Stay-at-Home. Gov. Larry Hogan has not issued a “stay-at-home” order. However, in interpretive guidance issued on March 23, 2020, the governor urged Maryland residents to stay at home and employers to encourage work-from-home arrangements. In Maryland Executive Order No. 20-03-23-01, issued on March 19, 2020, casinos, racetracks, enclosed malls, recreational establishments, and certain other retailers were required to close.

Elective Surgeries. On March 23, 2020, the secretary of state issued a Directive and Order Regarding Various Healthcare Matters . This order requires that all elective and non-urgent medical procedures and appointments cease effective 5 p.m. on March 24, 2020. As such, all providers licensed or certified under Maryland health professional law shall perform only medical procedures that are critically necessary for the maintenance of health for a patient.

Massachusetts

Stay-at-Home. Gov. Charles D. Baker issued Covid-19 Order No. 13 on March 23, 2020, which closes certain businesses that do not provide COVID-19 essential services, from 12 p.m. on March 24, 2020, through 12 p.m. on April 7, 2020. Additionally, the Massachusetts Department of Public Health issued a Stay-at-Home Advisory for individuals above the age of 70 and those with underlying health conditions.

Elective Procedures. The commissioner of the Massachusetts Department of Public Health, issued an order where all hospitals and ambulatory surgical centers are required to postpone or cancel any nonessential, elective invasive procedures. The guidance pursuant to the order indicates that these procedures are those scheduled in advance because the procedure does not involve a medical emergency. Examples of these procedures are highlighted within the guidance (found here), and include the following:

1. Any procedures involving skin incision
2. Injections of any substance into a joint space or body cavity
3. Orthopedic procedures (e.g. hip or knee replacement)
4. Endoscopy (e.g., colonoscopy, bronchoscopy, esophagogastric endoscopy, cystoscopy, percutaneous endoscopic gastronomy, J-tube placements, nephrostomy tube placements)
5. Invasive radiologic procedures
6. Dermatology procedures (e.g. excision and deep cryotherapy for malignant lesions- excluding cryotherapy for benign lesions)
7. Invasive ophthalmic procedures including miscellaneous procedures involving implants
8. Oral procedures (e.g., tooth extraction)
9. Podiatric invasive procedures (e.g., removal of ingrown toenail)
10. Skin or wound debridement
11. Kidney stone lithotripsy
12. Colposcopy and/or endometrial biopsy

The ultimate decision to cancel or postpone must be based upon the clinical judgement of the caring physician. This order is effective March 18, 2020, through the end of the state of emergency in Massachusetts, or until rescinded.

Michigan

Stay-at-Home. Effective March 24, 2020, through April 12, 2020 at 11:59 p.m., Gov. Gretchen Whitmer of Michigan issued Executive Order 2020-21, ordering all individuals to stay at their place of residence. The order prohibits public and private gatherings of any number of people not part of a single household as well. Individuals or entities are prohibited from operating a business or conducting operations that require workers to leave their homes.

Elective Medical and Dental Procedures. Gov. Whitmer issued Executive Order 2020-17, effective between March 21, 2020, and until the state of emergency is in effect. This order requires all hospitals, freestanding surgical outpatient facilities, and dental facilities to implement a plan to postpone all non-essential procedures.

A non-essential procedure under this order is defined as a medical or dental procedure that is not necessary to address a medical emergency or preserve the health and safety of a patient. Plans at medical centers to perform certain procedures such as joint replacement, bariatric surgery, and cosmetic surgery must at minimum be postponed unless it is emergent or trauma-related where postponement would significantly impact the health and welfare of the patient.

Dental procedures that must be postponed, at a minimum, include the following: cosmetic or aesthetic procedures; routine hygiene appointments; orthodontic procedures that do not relieve pain or infection, do not restore oral function, or are not trauma-related.

Minnesota

Stay-at-Home. Minnesota does not appear to have issued a stay-at-home order.

Elective Procedures. Gov. Tim Walz issued Executive Order 20-09, effective March 23, 2020, directing that 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 a non-essential surgery as one “that can be delayed without undue risk to the current or future health of a patient.” The governor’s order also provides examples of criteria to consider when making a decision as to whether a procedure is non-essential or elective:

1. Threat to the patient’s life if surgery or procedure is not performed.
2. Threat of permanent dysfunction of an extremity or organ system, including teeth and jaws.
3. Risk of metastasis or progression of staging.

Mississippi

Stay-at-Home. Mississippi does not appear to have issued a stay-at-home order.

Elective Procedures. On March 19, 2020, the Mississippi Department of Health issued a Health Alert Network Alert, which provides that all elective medical procedures and non-essential medical visits must be postponed. The alert also notes that physicians, hospitals, and medical centers must postpone elective surgical and diagnostic procedures until the COVID-19 situation has lessened and the supply of PPE is restored. Dentists are also specifically directed to delay non-emergency or routine dental procedures.

New Jersey

Stay-at-Home. Gov. Phil Murphy issued Executive Order No. 107 on March 21, 2020, ordering residents to stay at their homes and the closure of all brick and mortar non-essential retail businesses. Healthcare providers and facilities have already been deemed “essential.” The governor’s orders only discuss elective procedures in the context of noting that all day spas and medical spas at which solely elective and cosmetic procedures are performed must close.

Elective Procedures. Effective March 27, 2020 at 5 p.m., Gov. Murphy issued Executive Order No. 109, providing that all elective surgeries and invasive procedures performed on adults, whether medical or dental, are suspended in the state. The term elective is defined 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. An ‘elective’ surgery or invasive procedure does not include the administration of vaccines.” Providers are also directed to consider any post-operative complications that may place additional stress on local hospitals that do not have the capacity to accept transfers and the need to coordinate any possible post-operative admissions with local hospitals prior to performing any surgeries. It further directs ASCs to coordinate any possible post-surgery admissions with local hospitals prior to performing any surgeries.

Further, each hospital and ASC must develop written guidelines to ensure adherence to the provisions of this order and provide a copy of these guidelines to the New Jersey Department of Health. The guidelines developed must include a process for the treating provider about a designation that the surgery is elective under the terms of this order.

New Mexico

Stay-at-Home. Effective March 24, the New Mexico Stay-at-Home order issued by Gov. Michelle Lujan Grisham closes all non-essential businesses and requires those businesses that can to work from home. Similar to other states, essential healthcare services and operations will continue to be provided under the order.

Elective Procedures. On March 24, 2020, the New Mexico secretary of public health issued a public health order prohibiting all hospitals, ambulatory surgical facilities, dental orthodontic and endodontic officers in New Mexico from providing non-essential health care surgeries, procedures, and services. This order is to stay in effect until the state of emergency in New Mexico is over.

New York

Stay-at-Home. On March 20, 2020, Gov. Andrew Cuomo of New York issued the New York State on Pause Executive Order, which is a 10-point policy to address the COVID-19 outbreak. This order directs that as of 8 p.m. on March 22, 2020, all non-essential businesses statewide must close in-person operations. Further, an entity providing essential services or functions whether to an essential business or a non-essential business shall not be subjected to the in-person work restriction, but may operate at the level necessary to provide such service or function. The governor has also issued Guidance on Essential Services under the New York on Pause Executive Order, which provides that certain essential businesses that may continue with in-person operations include essential health care operations such as:

1. research and laboratory services
2. hospitals
3. walk-in-care health facilities
4. emergency veterinary and livestock services
5. elder care
6. medical wholesale and distribution
7. home health care workers or aides for the elderly
8. doctor and emergency dental
9. nursing homes, or residential health care facilities or congregate care facilities
10. medical supplies and equipment manufacturers and providers

Elective Procedures. In a speech on March 21, Gov. Cuomo also ordered the cancellation of all elective surgeries in New York starting on March 25, 2020. There does not yet appear to be any specific guidance regarding on what is an elective surgery, so we recommend that all providers continue to make their clinical judgments in line with the CMS and CDC guidelines and continue to document the need for any surgeries to illustrate why such procedures are necessary.

North Carolina

Stay-at-Home. North Carolina does not appear to have issued a stay-at-home order.

Elective Procedures. The North Carolina Department of Health and Human Services issued a letter on March 20, 2020, requesting that effective March 23, 2020, all hospitals and ASCs suspend all elective and non-urgent surgeries and procedures. These are defined as “any procedure or surgery that if not done within the next four weeks would cause harm to the patient.” The letter also notes that hospitals and ASCs, starting on March 20, 2020, should institute an explicit, real-time review of all non-time-sensitive surgeries and procedure.

Ohio

Stay-at-Home. The director of the Ohio Department of Health (ODH) issued a “stay-at-home” Order” effective 11:59 p.m. on March 23, 2020 through April 6, 2020, unless the director of ODH modifies the order. Under this order, all business and operations in Ohio except essential businesses and operations are ordered to cease all activities except for minimum basic operations. Essential businesses and operations include healthcare and public health options, which in turn is purposely defined broadly to avoid any impacts on the delivery of healthcare and includes, but is not limited to the following: hospitals; clinics; dental offices; pharmacies; public health entities, including those that compile, model, analyze and communicate public health information; pharmaceutical, pharmacy, medical device and equipment, and biotechnology companies (including operations, research and development, manufacture, and supply chain); organizations collecting blood, platelets, plasma, and other necessary materials; licensed medical marijuana dispensaries and licensed medical marijuana cultivation centers; obstetricians and gynecologists; eye care centers, including those that sell glasses and contact lenses; home healthcare services providers; mental health and substance use providers; other healthcare facilities and suppliers and providers of any related and/or ancillary healthcare services; and entities that transport and dispose of medical materials and remains.

Healthcare and public health options allowed to remain operational also include manufacturers, technicians, logistics, and warehouse operators and distributors of medical equipment, PPE, medical gases, pharmaceuticals, blood and blood products, vaccines, testing materials, laboratory supplies, cleaning, sanitizing, disinfecting or sterilization supplies, and tissue and paper towel products as well as veterinary care and all healthcare services provided to animals.

Elective Procedures. Effective at 5 p.m., March 18, 2020, Gov. Mike DeWine announced that the Ohio Department of Health issued an order that all “non-essential or elective surgeries and procedures that utilize PPE should not be conducted.” The order defines a non-essential surgery as “a procedure that can be delayed without undue risk to the current or future health of a patient.” The order also provides the following examples of criteria for providers to consider:

1. Threat to the patient’s life if 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; or
4. Risk of rapidly worsening to severe symptoms (time sensitive).

The order also includes directs providers to eliminate all non-essential individuals from surgery/procedure rooms and patient care areas to preserve PPE.

Oklahoma

Stay-at-Home. Oklahoma does not appear to have issued a stay-at-home order.

Elective Procedures. On March 24, 2020, Gov. Kevin Stitt issued the Fourth Amended Executive Order 2020-07, ordering that all medical providers postpone all elective surgeries, minor procedures, and non-emergency dental procedures until April 7, 2020. There are no specific criteria or guidelines listed for what constitutes an elective or non-emergency procedure.

Oregon

Stay-at-Home. Effective March 23, 2020 until terminated by Gov. Kate Brown , Oregon Executive Order No. 20-12 prohibited non-essential activities if a distance of at least six-feet cannot be maintained, prohibited individuals from patronizing non-essential businesses, and included a carve-out for indoor and outdoor malls that may provide carryout food, health care, medical, pharmaceutical or pet store services. Grocery, health care, medical, and pharmacy services are allowed to remain open are encouraged to comply with social distancing guidelines.

Elective Procedures. In an effort to preserve PPE and health care resources, Gov. Brown issued Oregon Executive Order No. 20-10. Effective from March 23, 2020, through June 15, 2020, the order requires all elective and non-urgent procedures across all settings that utilize PPE for non-COVID-19 elective procedures, including hospitals, ASCs, outpatient clinics, dental clinics, and veterinary clinics to be canceled or rescheduled no earlier than June 15, 2020. Procedures are exempt if a three month delay would put patients at risk of irreversible harm. Criteria to determine irreversible harm include the following:

1. Threat to a patient’s life;
2. Threat of irreversible harm to the patient’s physician or mental health;
3. Threat of permanent dysfunction of an extremity or organ system;
4. Risk of metastasis or progression of staging; and
5. Risk of rapidly worsening to sever symptoms.

Additionally, no later than March 27, 2020, this Executive Order requires hospitals, ASCs, outpatient clinics, dental clinics, and veterinary clinics with surplus PPE to notify the state PPE coordinator and deliver surplus PPE to the PPE coordinator.

Pennsylvania

Stay-at-Home. Gov. Tom Wolf issued an order on March 20, 2020, ordering the closure of all non-life-sustaining business close effective as of 12:01 a.m. on March 21, 2020. The governor’s office also provided a list of businesses that may continue physical operations that allows healthcare and social assistance services such as physician and practitioner offices, ambulatory surgery centers, home health agencies, nursing homes and hospitals to continue to operate, but specifically noted that all elective procedures are prohibited.

Elective Procedures. The Pennsylvania Department of Health also issued Guidance on Ambulatory Surgical Facilities' Responses to COVID-19 regarding elective procedures that is instructive. The guidance notes that ASCs “may not perform any elective surgeries or procedures unless the surgery or procedures are life-sustaining measures relating to a progressive disease, such as cancer, vascular disease or organ failure.” The Department of Health also notes that ASCs must consult CMS guidelines on elective surgery and procedures prior to making a cancellation decision. The Department of Health’s guidance and CMS guidelines, read together, indicate that allowable procedures include such life-sustaining measures that are procedures or interventions likely to be necessary to sustain the life of a patient with a progressive disease (similar to Pennsylvania’ definitions of life-sustaining treatment in the context of an advance directive), preserve organ function, and avoid future serious harm (but, note that the CMS guidelines urge ASCs to consider postponing intermediate surgeries for otherwise healthy patients whose condition is not currently life-threatening but has the potential for future morbidity).

Tennessee

Stay-at-Home. Tennessee does not appear to have issued a stay-at-home order.

Elective Procedures. Gov. Bill Lee issued Executive Order No. 18, effective March 24, 2020 through April 13, 2020, prohibiting both dental and medical non-essential procedures. The order specifies that dental service providers must not perform any non-emergency dental or oral procedures. Non-emergency procedures including hygiene visits, cosmetic procedures, and other elective procedures. Further, the order does state that emergency procedures with acute dental needs may still be performed, which includes treatment for pain, swelling, trauma, or an abscess.

Regarding medical procedures, the governor’s order directs that all hospitals and outpatient surgical facilities 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.” These facilities are directed to postpone, “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.” Further, the order provides examples of procedures that do not have to be postponed, such as, “surgeries related to advanced cardiovascular disease (including coronary artery disease, heart failure, and arrhythmias) that would prolong life; oncological testing, treatment, and related procedures; pregnancy-related visits and procedures, including labor and delivery; organ transplantation; procedures related to dialysis; and emergency or trauma-related procedures where postponement would significantly impact the health, safety, and welfare of the patient.”

Texas

Stay-at-Home. Texas does not appear to have issued a stay-at-home order.

Elective Procedures. On March 22, 2020, Gov. Greg Abbott issued Executive Order No. GA-09, effective through April 21, 2020, directing that all licensed health care professionals and licensed health care facilities must “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 also provides that this prohibition does not apply to the performance of any procedure, in accordance with the commonly accepted standard of clinical practice, would not deplete hospital capacity or PPE needed to address the COVID-19 disaster.

Utah

Stay-at-Home. Utah does not appear to have issued a stay-at-home order.

Elective Procedures. Effective March 25, 2020, the Utah Department of Health issued a State Public Health Order providing that all licensed health care professionals must postpone all elective surgeries and procedures in accordance with the CMS recommendations. The order remains in effect until April 25, 2020.

Virginia

Stay-at-Home. Virginia does not appear to have issued a stay-at-home order.

Elective Procedures. Gov. Ralph Northam and the Virginia state health commissioner issued Order of Public Emergency Two, on March 25, 2020, prohibiting all inpatient and outpatient surgical hospitals, freestanding endoscopy centers, physicians’ offices, and dental, orthodontic, and endodontic offices in Virginia from performing 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 does not affect or include outpatient visits in hospital-based clinics. Further, the governor’s order does not affect or apply to “the full suite of family planning services and procedures nor to treatment for patients with emergency or urgent needs.” All of the above listed facilities and providers may perform a procedure “that if delayed or canceled would result in the patient's condition worsening.” ASCs are also urged to work with local inpatient hospitals to assist with any needs.

Washington

Stay-at-Home. Gov. Jay Inslee issued Executive Order No. 20-25, effective March 23, 2020 through April 6, 2020, ordering that all people in Washington must cease leaving their home or residence except to conduct or participate in essential activities or for employment in essential business services. Healthcare has been included as an essential business service, therefore, healthcare professionals and facilities may still operate in-person services and treatment. The order also specifies that, effective March 25, 2020 through April 8, 2020, all non-essential businesses shall cease operations. Again, healthcare is listed as an essential business and may continue to operate.

Elective Procedures. On March 19, 2020, Gov. Inslee issued Executive Order No. 20-24, prohibiting all hospitals, ambulatory surgical facilities, dental, orthodontic, and endodontic offices “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, with exceptions and as provided below.” The prohibition does not include outpatient visits in hospital-based clinics. The order also provides examples of procedures to delay, such as “most joint replacements, most cataract and lens surgeries, non-urgent cardiac procedures, cosmetic procedures, some endoscopy, and some interventional radiology services.” Further, the governor’s order does not apply to the full suite of family planning procedures or to services for patients with emergency needs, examples of which include “people with heart attacks, strokes, or motor vehicle accidents.” Hospitals and ASCs are specifically allowed to perform any surgery or procedure, “that if delayed or canceled would result in the patient’s condition worsening (for example, removal of a serious cancerous tumor or dental care related to the relief of pain and management of infection).”

Wisconsin

Stay-at-Home. Effective March 25, 2020, through April 24, 2020, the Secretary of the Department of Health Services issued Emergency Order #12. The order requires individuals present within Wisconsin to stay at their place of residence and prohibits public and private gathering of members of a single household. Healthcare has been included as an essential business service, and may continue to operate.

Elective Procedures. Wisconsin has not yet prohibited elective surgeries. Guidance from the Wisconsin Department of Health, DPH Numbered Memo 2020-14 does recommend that dental practices postpone all elective and non-urgent care treatment.