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

April 09, 2020

CHICAGO (April 9, 2020): Within a month of the University of California San Francisco (UCSF) Health treating its first patient with coronavirus disease 2019 (COVID-19) on Feb. 3, UCSF surgeons began formulating a plan to respond to the pandemic and help manage the health care system's available resources. The comprehensive rapid response plan--one of the earliest surgical strategies for handling the outbreak reported in the nation--appears online as an "article in press" on the Journal of the American College of Surgeons website in advance of print.


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


"In two weeks, we have dramatically changed the way we approach surgical care and come together as a community for the greater good of our city and patients. The speed with which this has occurred is unprecedented," the authors write. "Our response efforts were early and aggressive, and we made tough decisions," said study coauthor Elizabeth Wick, MD, FACS, professor of surgery at UCSF. "We canceled elective surgical cases before any other facility in the country that we know of. By starting early, we figured out a way to focus on urgent operations before the situation became worse."


Prioritizing operations


On March 13, the American College of Surgeons (ACS)1 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, or assign degrees of urgency to, scheduled operations, and was followed with another guidance document on March 17 to aid in surgical decision making to triage operations.2 Even before then, in early March, the UCSF department of surgery had already developed triage guidelines for operations, according to Dr. Wick.


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 Dr. Wick said is helping with organizing the case backlog.


As virus-related health care 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. Additionally, they considered whether nonsurgical treatment was an option.


From an initial 25 percent reduction in operating room volume starting on March 2, the surgeons succeeded in lowering the surgical volume by 80 percent in mid-March, Dr. Wick reported.


Because adjusting surgical care was a crucial step in managing available health care resources, she said surgeons had representation on all UCSF COVID-19 work committees.


Reassigning surgeons to optimize workforce


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 health care 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, Dr. Wick said.


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.


Putting patients first


It is too soon, Dr. Wick noted, to know whether their rapid response improved outcomes for patients and staff. She said, "We hope we took the necessary measures that will allow UCSF Health to continue to safely and effectively care for surgical patients requiring urgent operations as well as for COVID-19 patients."


She credits their 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 nonurgent operations postponed, Dr. Wick said. She also commended strong departmental leadership that emphasized that everyone should prioritize "what was right for the patients."


Dr. Wick said her team members decided to quickly publicize their response plan hoping their experience would help other surgical facilities navigate "this uncharted territory." She said their plan is scaleable to other health care systems and smaller hospitals that have strong leadership and good communication about the purpose of the changes.
-end-
Study coauthors are Elizabeth M. Lancaster, MD; Julie A. Sosa, MD, MA, FACS; Logan Pierce, MD; Wen Shen, MD, FACS; and Michael Conte, MD, FACS, all from UCSF; and Amanda Sammann, MD, FACS, of Zuckerberg San Francisco General Hospital.


The authors have no disclosures to report.


"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.


Citation: Rapid Response of an Academic Surgical Department to the COVID-19 Pandemic: Implications for Patients, Surgeons, and the Community. Journal of the American College of Surgeons. DOI: https://doi.org/10.1016/j.jamcollsurg.2020.04.007


1 American College of Surgeons. COVID-19: Recommendations for Management of Elective Surgical Procedures. https://www.facs.org/covid-19/clinical-guidance/elective-surgery. March 13, 2020. Accessed April 3, 2020.

2 American College of Surgeons. COVID-19: Guidance for Triage of Non-emergent Surgical Procedures. https://www.facs.org/about-acs/covid-19/information-for-surgeons/triage. March 17, 2020. Accessed April 3, 2020.


About the American College of Surgeons

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 82,000 members and is the largest organization of surgeons in the world. For more information, visit http://www.facs.org.

American College of Surgeons

Related Pandemic Articles from Brightsurf:

Areas where the next pandemic could emerge are revealed
An international team of human- and animal health experts has incorporated environmental, social and economic considerations -- including air transit centrality - to identify key areas at risk of leading to the next pandemic.

Narcissists love being pandemic 'essential workers'
There's one group of essential workers who especially enjoy being called a ''hero'' during the COVID-19 pandemic: narcissists.

COVID-19: Air quality influences the pandemic
An interdisciplinary team from the University of Geneva and the ETH Z├╝rich spin-off Meteodat investigated possible interactions between acutely elevated levels of fine particulate matter and the virulence of the coronavirus disease.

People who purchased firearms during pandemic more likely to be suicidal
People who purchase a firearm during the pandemic are more likely to be suicidal than other firearm owners, according to a Rutgers study.

Measles outbreaks likely in wake of COVID-19 pandemic
Major measles outbreaks will likely occur during 2021 as an unexpected consequence of the COVID-19 pandemic, according to a new academic article.

The COVID-19 pandemic: How US universities responded
A new George Mason University study found that the majority of university announcements occurred on the same day as the World Health Organization's pandemic declaration.

Researchers find evidence of pandemic fatigue
A new study from the USC Leonard Davis School of Gerontology shows that the behavioral responses to COVID-19 differed by age.

Excessive alcohol consumption during the COVID-19 pandemic
The full impact of COVID-19 on alcohol use is not yet known, but rates have been rising during the first few months of the pandemic.

How fear encourages physical distancing during pandemic
Despite guidelines plastered on the walls and floors of grocery and retail stores encouraging customers to maintain six-feet of physical distance during the pandemic, many do not.

COVID-19 pandemic and $16 trillion virus
This Viewpoint aggregates mortality, morbidity, mental health conditions, and direct economic losses to estimate the total cost of the pandemic in the US on the optimistic assumption that it will be substantially contained by the fall of 2021.

Read More: Pandemic News and Pandemic Current Events
Brightsurf.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.