Triaging surgical procedures during pandemics
Coronavirus disease-2019 (COVID-19) is a major pandemic caused by an RNA virus named Severe Acute Respiratory Syndrome—Coronavirus 2 (SARS- CoV-2).
This pandemic has already been labelled as a Public Health Emergency of International Concern by the World Health Organization (WHO). Besides the direct effect of the COVID-19 pandemic on public health, disruption of the economy, it has also caused disruptions and cancellations of many kinds of surgical services.
Time and again, due to various reasons, most of the health systems around the world have experienced seasonal disruptions of surgical care and infrequent cancellations of surgeries. However, the current pandemic has had unprecedented effects on surgical services and patients requiring surgical care.
During natural disasters which lead to mass casualties, the surgical capacity of any health system might experience extreme challenges. In other words, the number of casualties might exceed the surgical capacities—both in terms of manpower like surgeons, anesthesiologists and other medical staff or the available infrastructure like operating rooms, post-operative wards, intensive care beds etc.
Moreover, the current demand for the increased number of ventilators, wards, intensive and high dependency beds and staff for the care of the Covid-19 patients is depriving the surgical capacity of the entire health system. This has a severe, immediate and long-term impact on a large number of patients around the world with various kinds of surgical conditions.
In order to cope up with the situation, hospitals are cancelling elective surgeries to preserve limited resources available to them for managing the potential surge of coronavirus cases.
There is a general belief that the continuing regular elective surgical services contribute to the spreading of the coronavirus within facilities. However, we need to understand that elective surgery doesn’t necessarily mean it’s optional treatment. Rather, it implies that the surgical intervention is not immediately required in such procedures and that they may be postponed for a limited period of time without causing serious effects on the individual patients. Procedures requiring immediate attention are considered as surgical emergencies. But it’s important that we pay attention also to those ‘elective’ procedures, according to experts, more than 50 percent of them have the potential to cause significant harm to patients if cancelled or delayed.
We need to reconsider or redirect the surgical services by reconsidering management strategies to prepare for different phases of a pandemic.
In the absence of timely intervention, the condition of the patients requiring surgical care might not just decline but they will also become very vulnerable to coronavirus infections.
Many of these non-urgent surgical conditions, labelled as electives, at some point of time will become urgent and will definitely depend upon how long this Covid-19 pandemic persists.
Worldwide, there is a growing debate about the safety and feasibility of continuing elective surgical procedures during the Covid-19 pandemic. We also need to understand that cancellations of these procedures may have a more immeasurable impact on the health of our communities than the morbidity and mortality caused by Covid-19.
Planning and decisions based on underlying risk stratification and available resource utilisation will definitely assure the access of our patients to timely and appropriate surgical care. At the same time, it also helps in maintaining unwavering stewardship for the limited resources, manpower available and emergency preparedness at the hospitals.
On one hand, we have to work with the limited available resources to cope with this pandemic. On the other, we have to keep in mind that any delay in treatment, especially of cancers, trauma and life-threatening conditions, may lead to adverse outcomes in the pandemic phase; there is always a threat of disruption of all surgical services and critical care services. Worldwide, different centres and surgical societies have come up with guidelines for prioritising the surgical procedures during pandemics. These guidelines have been prepared to help the surgeons on listing the different surgical procedures during all phases of pandemics—pre-pandemic, pandemic and post-pandemic phases.
However, there is no single complete guideline incorporating every aspect of delivering surgical services during pandemics. Most of them are based on common principles and are being updated regularly.
In order to prioritise the types of surgery, This is done to reduce admissions, avoid surgeries whenever feasible, delay interventions, finally helping in the preservation and utilisation of resources for the pandemics.
How can it be done?
Based on the underlying assumptions and uncertainty, it is difficult to properly design and implement clinically relevant and patient safety-driven algorithms which could help in decision-making for delivering appropriate surgical care in the most rational way.
Some have simply classified the procedure into ‘essential’, which means that there is an increased risk of untoward events if surgical procedures are delayed for the prolonged period as compared to ‘non-essential’ ones, which are purely elective procedures that are not time-sensitive.
Moreover, it’s important that we understand the template management of a specific condition is not possible. Every patient needs to be evaluated individually. There is no universal consensus on defining elective versus emergency surgical procedures. It varies between surgeons, centres and different specialities. Most of the recommendations produced by different societies are a general recommendation that needs to be modified based on local resources and practices.
Various factors need to be considered while triaging the surgical procedures of any disciplines, including assessment of the risk of disease, its progression and overall impact on delaying the treatment, the available alternative treatment options and the available local resources. While choosing treatment, clinicians should opt for the ones requiring the shortest hospital stay, fewest complications, least likelihood of needing critical care service, lowest utilisation of resources. Besides, there should be the lowest risk of transmitting the pandemic disease to healthcare workers.
In short, triaging surgical procedures should be defined based on the procedure-related factors, disease factors and patient-related factors and of course considering the local resources.
In an article published in the Journal of the American College of Surgeons in April 2020, a team of investigators from the University of Chicago has devised a new scoring system known as Medically Necessary Time-Sensitive (MeNTS) Prioritization. It is helpful for surgeons across different surgical specialities in deciding when to proceed with necessary surgeries in the face of the resource constraints and increased risk posed by COVID-19 pandemic.
Hospitals are cancelling elective surgeries to preserve limited resources available to them for managing the potential surge in coronavirus cases.
The National Health Service (UK) has defined surgical procedures at different priority levels. Priority Level 1a Emergency, operation needed within 24 hours; Priority Level 1b Urgent, operation needed with 72 hours; Priority Level 2 Surgery that can be deferred for up to four weeks; Priority level 3 Surgery that can be delayed for up to three months; and Priority level 4 Surgery that can be delayed for more than three months. This is applied to all the sub-specialities of surgery. According to the American College of Surgeons bulletin, each hospital, health system, and surgeon should thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations until the predicted inflection point has passed.
While preparing for triaging the surgical procedures, besides reorganising the surgical force and reconsidering the choice of managements as mentioned earlier it’s equally important to plan for the post-pandemic phase. As the cancellation and delaying during pandemic phase will create a huge backlog of patients. Rebuilding the surgical capacity after a pandemic should be in plans from the beginning.
In the end, every institute requires a structured framework to deliver national-level surgical care by efficiently triaging the surgical procedures during the Covid-19 pandemic. It is equally important to learn from the experience of other countries how the effects of the pandemic on surgical services were mitigated and what were the most rational ways of surgical services delivered.
Dr Bhandari is professor of Gastrointestinal Hepatopancreatobiliary and Liver Transplantation at TUTH.