Online March 17, 2020
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In response to the rapidly evolving challenges faced by hospitals related to the Coronavirus Disease 2019 (COVID-19) outbreak, and broad calls to curtail “elective” surgical procedures, the American College of Surgeons (ACS) provides the following guidance on the management of non-emergent operations.
It is not possible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. While some cases can be postponed indefinitely, the vast majority of the cases performed are associated with progressive disease (such has cancer, vascular disease and organ failure) that will continue to progress at variable, disease-specific rates. As these conditions persist, and in many cases, advance in the absence of surgical intervention, it is important to recognize that the decision to cancel or perform a surgical procedure must be made in the context of numerous considerations, both medical and logistical. Indeed, given the uncertainty regarding the impact of COVID-19 over the next many months, delaying some cases risks having them reappear as more severe emergencies at a time when they will be less easily handled. Following careful review of the situation, we recommend the following:
In general, a day-by-day, data-driven assessment of the changing risk-benefit analysis will need to influence clinical care delivery for the foreseeable future. Plans for case triage should avoid blanket policies and instead rely on data and expert opinion from qualified clinicians and administrators, with a site-specific granular understanding of the medical and logistical issues in play. Finally, although COVID-19 is a clear risk to all, it is but one of many competing risks for patients requiring surgical care. Thus, surgical procedures should be considered not based solely on COVID-associated risks, but rather on an assimilation of all available medical and logistical information.
To further assist in the surgical decision-making process to triage non-emergent operations, ACS suggests that surgeons look at the Elective Surgery Acuity Scale (ESAS) from St. Louis University (below). Each surgical specialty has specific guidelines that are pertinent to the procedures within that specialty. We gratefully acknowledge and thank Allan Kirk, MD, PhD, FACS, and Sameer Siddiqui, MD, FACS, for their contributions and recommendations to this document.
ACS will continue to follow up with additional recommendations and refinements, as needed.
Reprinted with permission: Sameer Siddiqui MD, FACS, St Louis University
Tiers/Description |
Definition |
Locations |
Examples |
Action |
Tier 1a
|
Low acuity surgery/healthy patient |
HOPD |
Carpal tunnel release |
Postpone surgery or perform at ASC |
Tier 1b
|
Low acuity surgery/unhealthy patient |
HOPD |
Postpone surgery or perform at ASC
|
|
Tier 2a
|
Intermediate acuity surgery/healthy patient |
HOPD |
Low risk cancerNon urgent spineUreteral colic
|
Postpone surgery if possible or consider ASC
|
Tier 2b
|
Intermediate acuity surgery/unhealthy patient |
HOPD |
Postpone surgery if possible or consider ASC
|
|
Tier 3a
|
High acuity surgery/healthy patient |
Hospital
|
Most cancers |
Do not postpone
|
Tier 3b
|
High acuity surgery/unhealthy patient |
Hospital
|
Do not postpone
|
HOPD – Hospital Outpatient Department
ASC – Ambulatory Surgery Center