FARGO — Sanford Health and other hospitals in North Dakota are still conducting elective surgeries after federal officials and medical groups have urged U.S. health care providers to stop those procedures during the coronavirus pandemic.

But North Dakota health leaders say the debate is more complex than some may realize.

On March 14, U.S. Surgeon General Jerome Adams asked hospitals to consider halting elective surgeries while retweeting a March 13 post by the American College of Surgeons about guidelines on rescheduling such procedures. The Centers for Disease Control and Prevention also has said to reschedule elective surgeries “as necessary," while other government agencies and health care organizations have provided guidelines.

The move could help prevent the coronavirus from coming into facilities, preserve supplies and make space for hospitals to handle an expected increase in infected patients, Adams' office said in a written statement.

"Suspending nonessential surgeries and procedures is imperative for our national COVID-19 response,” the statement said, noting the decision should be made by health care providers and patients.

As of Friday, April 3, thirty-three governors had recommended postponing elective surgeries or signed executive orders that ban nonessential procedures until further notice, including Minnesota and South Dakota. North Dakota Gov. Doug Burgum said he doesn’t plan to do that because he wants the decision to be made by local providers.

“We want to be clear that there are some functions that we want the hospitals to continue to do right now because the stuff that they’re doing is also improving health and saving lives and doing all that,” Burgum said during a news conference Tuesday, March 31.

Sanford Medical Center in Fargo continues to conduct elective surgeries on a case-by-case basis, though the hospital said more patients are rescheduling the procedures. Sanford, a nonprofit health system headquartered in Sioux Falls, S.D., declined a phone interview on the topic but said in a written statement it has a process that allows physicians to decide with patients whether to reschedule nonessential surgeries.

“Physicians are best equipped to do this because they know their patients’ needs better than anyone and we are proud of how they’ve responded,” Dr. Doug Griffin, Sanford's chief medical officer in Fargo, said in the statement. “Bottom line for patients is they will continue to get the care they need and deserve.”

There has been a debate on whether states should issue bans on elective surgeries, and some fear hospitals who don't cease such procedures could expose patients to coronavirus.

But saying a hospital has halted its elective surgeries isn’t as “black and white” as some may think because the term elective is so broad, said Meghan Compton, executive vice president and chief clinic operations officer at Altru Health System in Grand Forks, N.D. Many don't understand what elective entails, she added.

“The definition in the health care world is different than what the general public thinks the definition is,” she said.

What does elective mean?

An elective surgery is any procedure that is scheduled in advance, as opposed to emergency surgeries. Elective procedures can include breast augmentation, removing a brain tumor, extracting kidney stones and carotid artery surgery that could prevent a stroke, to name a few.

They can be broken down into essential and nonessential procedures, North Dakota Hospital Association President Tim Blasl said. Essential surgeries are time sensitive and can impact quality of life if not done sooner rather than later, he said.

“Let’s just say you come in with a lump, and you need this removed,” he said. “You can’t wait two months. That still needs to be done.”

It’s unclear how many hospitals around the U.S. are rescheduling elective surgeries. But most health care facilities are taking the advice of the CDC and the surgeon general, or at least preparing to do so, said Dr. David Hoyt, executive director for the American College of Surgeons.

Hospitals are interpreting the recommendations differently, he said. To those who aren’t postponing the procedures, “I think they need to reconsider,” he said.

The American Hospital Association, which did not respond to requests for comment, called the surgeon general's comments “blanket statements” in a March 15 statement. The organization agreed the crisis may require some procedures to be delayed, but health care providers “cannot completely cease caring for illness in our community that is not directly related to the COVID-19 crisis.”

The NDHA advised hospitals in North Dakota to determine which procedures can be delayed, and which ones need to proceed. “North Dakota is a state known for its independence, but it is also a state that makes decisions based on common sense and those principles which support the collective good of all North Dakotans,” the NDHA said in a statement.

Who's postponing?

Essentia Health, which is headquartered in Duluth, Minn., and has a hospital in Fargo, announced March 17 it would postpone elective surgeries if the delay would “not adversely impact a patient’s condition,” making it an early health care provider to follow federal recommendations. Essentia will continue to follow those guidelines “as long as there’s a significant risk,” said Dr. Rich Vetter, chief medical officer for the health care provider.

“The idea behind that is to preserve the precious resources, not only the … personal protective equipment, but also the staff, the providers and the community from unnecessary exposure,” said Al Hurley, chief operating officer for Essentia’s west market.

Restrictions also were placed on elective surgeries at Catholic Health Initiative hospitals in North Dakota as of March 20. Nonemergent cases were deferred, a spokeswoman said.

Altru has ceased most of its elective surgeries but still performs a smaller number, Compton said. The move has resulted in a 60% drop in total surgeries.

“The way that we are thinking about it and the way that we are talking to our patients about it is, if something is time-sensitive, we are going to work with those patients to make sure that we take care of them,” Compton said.

Sanford’s surgical volume has dropped about 30% in recent weeks, Griffin said in the statement. Essentia has seen similar numbers, Hurley said.

'An informed decision'

Minnesota Gov. Tim Walz signed an executive order on March 19 halting "nonessential or elective surgeries and procedures" beginning March 23 as long as postponing the procedure doesn’t cause undue risk to patients. South Dakota Gov. Kristi Noem issued an order that says health care facilities “should ... postpone all nonessential elective surgeries.” Sanford, which has facilities in South Dakota and Minnesota, said it would follow both orders.

In North Dakota, Burgum said elective surgeries make up a large portion of hospital revenue, and he doesn’t want to do economic damage to those who work in the health care industry or hurt patients who need surgeries. “In this case, a one-size-fits-all order from the state made no sense when we’ve got a bunch of responsible leaders that are managing and making those decisions on their own,” the governor said.

Sanford said “revenue is not playing a part in not suspending nonessential surgeries." Most of the surgeries performed in the last month were procedures that, "if postponed, could have resulted in infection, tumor growth, neuro motor dysfunction, excruciating pain and/or even death," the health care provider said.

“Our focus is on meeting the health care needs in our communities,” Griffin said. “We have the staff and supplies to do so, and it’s the right thing to do for our patients.”

Vetter of Essentia noted other businesses are taking measures to prevent the spread of the coronavirus, even if it means closing their doors and taking a financial hit. Essentia needed to respond in a similar fashion, he said.

“We did it with an informed decision that there would be a financial impact, but felt the health aspects outweighed that,” Vetter said.

Hoyt of the American College of Surgeons said finances should be a consideration when deciding whether to cut out elective surgeries.

“You don’t want to do it unnecessarily," he said. "You don’t want to do it prematurely.”

Still, he said the U.S. is beyond a period of judgment, and hospitals should follow national guidelines.

“If there are places where people are going to need someone to tell them to do that, then that’s the way it is going to develop,” Hoyt said. “Right now, the need (to postpone elective surgeries) is very, very strong.”