How to prioritize patients and redesign care to safely resume planned surgery during the COVID-19 pandemic

Abstract

Aims Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites. Methods A multidisciplinary surgical prioritization committee developed the SPAG, incorporating procedural urgency, shared decision-making, patient safety, and biopsychosocial factors; and applied it to 1,142 adult patients awaiting orthopaedic surgery. Patients were stratified into four priority groups and underwent surgery at three COVID-free sites, including one with access to a high dependency unit (HDU) or intensive care unit (ICU) and specialist resources. Safety was assessed by the number of patients requiring inpatient postoperative HDU/ICU admission, contracting COVID-19 within 14 days postoperatively, and mortality within 30 days postoperatively. Results A total of 1,142 patients were included, 47 declined surgery, and 110 were deemed high-risk or requiring specialist resources. In the ten-week study period, 28 high-risk patients underwent surgery, during which 68% (13/19) of Priority 2 (P2, surgery within one month) patients underwent surgery, and 15% (3/20) of P3 (< three months) and 16% (11/71) of P4 (> three months) groups. Of the 1,032 low-risk patients, 322 patients underwent surgery. Overall, 21 P3 and P4 patients were expedited to ‘Urgent’ based on biopsychosocial factors identified by the SPAG. During the study period, 91% (19/21) of the Urgent group, 52% (49/95) of P2, 36% (70/196) of P3, and 26% (184/720) of P4 underwent surgery. No patients died or were admitted to HDU/ICU, or contracted COVID-19. Conclusion Our widely generalizable model enabled the restart of planned surgery during the COVID-19 pandemic, without compromising patient safety or excluding high-risk or complex cases. Patients classified as Urgent or P2 were most likely to undergo surgery, including those deemed high-risk. This model, which includes assessment of biopsychosocial factors alongside disease severity, can assist in equitably prioritizing the substantial list of patients now awaiting planned orthopaedic surgery worldwide. Cite this article: Bone Jt Open 2021;2(2):134–140.

The Oxford Knee Score is a reliable predictor of patients in a health state worse than death and awaiting total knee arthroplasty

“…Therefore, the OKS seems to be more inclusive than exclusive when identifying those who may benefit from a TKA. Not all patients on a waiting list for a TKA are, however, equal and prioritizing according to pain severity and effects on socioeconomic consequences is difficult [ 8 , 10 , 28 ]. Rationing of TKA is inevitable when there are limited resources and demand exceeds capacity [ 12 ].…”

“…However, priority two surgery (within a month) applies to arthroplasty patients where delays may prejudice their outcome; priority three (less than three months) applies to avascular necrosis of the hip: and priority four (more than three months) applies to uncomplicated arthroplasty [ 9 ]. All patients listed for knee arthroplasty are not equal and priority four will not be applicable to all patients [ 10 ]. Objective prioritization of patients is difficult, and authors have suggested prioritizing according to scores, applied ethics, and knee-specific function [ 8 , 11 – 13 ].…”

Converting hip and knee arthroplasty cases to same-day surgery due to COVID-19

“…17 , 18 These guidelines were shown to be effective in minimizing COVID-19 exposure to operative patients. 19 Studies have also sought to identify strategies to safely reinstate orthopaedic procedures, such as stratifying elective patients at higher risk for COVID-19-related illness by assessing comorbidities and minimizing length of hospital stay. 20 Surrogates for elective surgery, such as the use of THA for hip fractures, also showcased the ability to provide arthroplasty services safely amid the COVID-19 pandemic.…”

Decision Conflicts in Clinical Care during COVID-19: A Patient Perspective

“…Therefore, these results are only in part comparable. However, the general picture of highly variable perception of pandemic effects on personal decision making by patients was similarly found in other entities, such as elective surgery, and in various countries, such as the UK [ 37 , 38 ].…”