Surgeons develop operation-triage plan to reduce OR volume during COVID-19 pandemic

Within a month of the University of California San Francisco Health treating its first patient with the COVID-19 coronavirus on February 3, UCSF surgeons began formulating a plan to respond to the pandemic and help manage the healthcare system's available resources.

The comprehensive rapid response plan -- one of the earliest reported surgical strategies for handling the outbreak -- appears online as an "article in press" on the Journal of the American College of Surgeons website in advance of print.

The multi-tier plan was a collaboration between the UCSF department of surgery and the hospital's other departments. Their actions included reducing operating room volume by 80% to ensure adequate capacity to care for an anticipated influx of COVID-19 patients, safeguarding personal protective equipment, preparing for a dwindling workforce due to illness and other reasons, and providing regular communication to departmental staff about the pandemic.

The response efforts were "early and aggressive," the authors wrote, and UCSF changed its approach to surgical care in about two weeks, being among the first facilities in the country to cancel elective surgeries.

WHAT'S THE IMPACT

On March 13, the American College of Surgeons recommended that hospitals consider postponing elective, nonurgent surgical procedures, thus freeing hospital beds and other resources for COVID-19 patients. This recommendation left it to individual institutions to determine how to triage scheduled operations, and was followed with another guidance document on March 17 to aid in surgical decision making to triage operations.

Even before then, in early March, the UCSF department of surgery had already developed triage guidelines for operations.

Initially, the multidisciplinary team of surgeons defined essential surgical cases as those that would result in an adverse outcome (such as disease progression) if the patient did not undergo the procedure within seven days. The surgeons flagged the priority level in each patient's electronic health record, which the authors said is helping with organizing the case backlog.

As virus-related healthcare shortages in other countries became news, the surgical team quickly responded with changes. They reportedly began to prioritize cases based on not only the expected results of delaying the procedure but also the extent that the procedure would use hospital resources, such as ventilators and blood. They also considered whether nonsurgical treatment was an option.

From an initial 25% reduction in operating room volume starting on March 2, the surgeons succeeded in lowering the surgical volume by 80% in mid-March. Because adjusting surgical care was a crucial step in managing available healthcare resources, surgeons had representation on all UCSF COVID-19 work committees.

WHAT ELSE YOU SHOULD KNOW

The department of surgery also developed a plan to optimize the workforce during the pandemic. For instance, the department reassigned some surgeons, based on their competencies, to work in inpatient units, the emergency department, or the system's Level I trauma center.

To minimize workers' exposure to the coronavirus, the department limited surgeons to work at a single hospital site in the healthcare system and reduced the number of surgeons on each surgical service daily. The same surgical team worked for several days straight so others would be available to work if a viral exposure occurred on that service.

Anticipating shortages of masks, the surgical department created guidelines for which types of PPE to wear in the operating room and when to wear single-use masks versus reusing them.

The authors credit the ability to implement a rapid COVID-19 response to San Francisco's early city ordinances requiring residents to stay home and mandating hospitals to restrict visitors. These directives helped patients understand the need to have their non-urgent operations postponed.

The plan, authors said, is scalable to other healthcare systems and smaller hospitals that have strong leadership and good communication about the purpose of the changes.

THE LARGER TREND

While the use of PPE has become a critical component of COVID-19 care, the simple act of acquiring PPE has become burdensome, and equipment shortages are one component of a toxic cycle of coronavirus-related challenges including insufficient tests, slow results and a dearth of ventilators for the highest-need patients.

These various challenges are playing off of each other and exacerbating the situation through a kind of domino effect, according to a report from the U.S. Department of Health and Human Services' Office of the Inspector General.

Twitter: @JELagasse

Email the writer: jeff.lagasse@himssmedia.com