“Where will you be doing my surgery?  I want to make sure it is at the hospital so everything is there in case of a ‘problem’.”  This was not an unusual request of a patient to a surgeon prior to the pandemic. 

What should we expect in the new world after COVID-19?  Sure, the hospitals have “everything.”  This “everything” may also include many things that are not in the best interest of care for foot and ankle patients.  It is time to re-evaluate and re-educate our patients on the risk benefit profile of surgical care location and the potential risks.  The increased risk for bacterial infection, and in particular, resistant bacterial infection such as MRSA has been recognized for years.  Despite this well recognized evidenced based literature discrepancy, many outpatient surgical procedures are still being performed in an inpatient hospital setting. 

There are certain risk factors that are inherent to patient risk factors.  Patients that require dialysis, complex airway management, and other more critical issues will likely always require the safety net of the inpatient setting.  But are there other factors involved in determining location of care for orthopaedic foot and ankle procedures?  What is the basis for preferential increased payment schedule for procedures performed in the inpatient hospital setting versus the outpatient surgical center?  Why are implant costs commonly paid for by insurers in the inpatient setting but must be absorbed and thus frequently not plausible in the outpatient setting for the same procedures?  Should patients with certain health care plans with limited outpatient surgical setting capacity be pigeonholed into having simple surgical procedures in a inpatient setting?  Can we perform cases that were traditionally considered “big” cases in the outpatient setting with pain management techniques that will allow for outpatient care?  Can we change Medicare guidelines to allow patients that will require assistance after surgery to receive such care without prolonged and often unnecessary days of hospitalization before qualifying for rehab setting transition?

The new normal for musculoskeletal surgery will be different after COVID.  Where would most surgeons want their wives to have their bunions fixed?  What about their dad’s hip replacement?  Their cousin’s flatfoot correction performed?  I don’t know many surgeons that would choose a hospital.