Prioritizing Surgical Services during on-Going Pandemic Response: Modification and Reliability of the Medically Necessary Time Sensitive Surgery (MeNTS) Scoring Tool

Abstract

Health systems are struggling to manage a fluctuating volume of critically ill patients with COVID-19 while continuing to provide basic surgical services and expand capacity to address operative cases delayed by the pandemic. As we move forward through the next phases of the pandemic, we will need a decision-making system that allows us to remain nimble as clinicians to meet our patient’s needs while also working with a new framework of healthcare operations. Here, we present our quality improvement process for the adaptation and application of the Medically Necessary Time-Sensitive (MeNTS) toolto gynecologic surgical services beyond the initial COVID response and into recovery of surgical services; with analysis of the reliability of the modified-MeNTS tool in our multi-site safety net hospital network. This multicenter study evaluated the gynecology surgical case volume at three tertiary acute care safety net institutions within the LA County Department of Health Services: Harbor-UCLA (HUMC), Olive View Medical Center (OVMC), and Los Angeles County + University of Southern California (LAC+USC). We describe our modified-Delphi approach to adapt the MeNTS tool in a structured fashion and its application to gynecologic surgical services. Blinded reviewers engaged in a three-round iterative adaptation and final scoring utilizing the modified tool. The cohort consisted of 392 female consecutive gynecology patients across three Los Angeles County Hospitals awaiting scheduled procedures in the surgical queue.The majority of patients were Latina (74.7%) and premenopausal (67.1%). Over half (52.4%) of the patients had cardiovascular disease, while 13.0% had lung disease, and 13.8% had diabetes. The most common indications for surgery were abnormal uterine bleeding (33.2%), pelvic organ prolapse (19.6%) and presence of an adnexal mass (14.3%). Minimally invasive approaches via laparoscopy, robotic-assisted laparoscopy, or vaginal surgery was the predominant planned surgical route (54.8%). Modified-MeNTS scores assumed a normal distribution across all patients within our cohort (Median 33, Range 18–52). Overall, ICC across all three institutions demonstrated “good” interrater reliability (0.72). ICC within institutions at HUMC and OVMC were categorized as “good” interrater reliability, while LAC-USC interrater reliability was categorized as “excellent” (HUMC 0.73, OVMC 0.65, LAC+USC 0.77). The modified-MeNTS tool performed well across a range of patients and procedures with a normal distribution of scores and high reliability between raters. We propose that the modified-MeNTS framework be considered as it employs quantitative methods for decision-making rather than subjective assessments.

Evaluation of the medically necessary, time sensitive triage score during and beyond the local COVID-19 pandemic in the Gynaecologic Oncology Unit of a tertiary hospital in South Africa

“…There was a good distribution of the score across the operated and non-operated groups in terms of age, disease types and surgery types. Similar normal distribution was reported by Saleeby et al and Marfori et al in their studies respectively [ 13 , 16 ]. The intermediate score group (score 55–59) forms the flexible range of the upper and lower threshold MeNTS score to determine who will be operated or postponed.…”

“…However, the severity of the comorbidity was only assessed by the number of medications taken by the patients rather than how impactful the condition is on their functionality. Only one-third of our participants had one or multiple comorbidities such as cardiovascular disease, lung disease or diabetes mellitus as compared to the 79% of the participants reported by the Saleeby et al [13]. We did not find any statistically significant difference in the cumulative mean score between those with or without comorbidity.…”

“…The median score in their study was 33 which was lower than 51 reported in our study. The majority of the studies where the MeNTS score was modified, reported lower cumulative mean scores than our finding [11][12][13][14]. This might be due to the differences in the weight allocated to each variable in the modified scores.…”

“…Saleeby and co-workers modified the MeNTS score to prioritize patients with benign gynaecologic conditions to different surgical modalities ranging from minimal access to open surgery [ 13 ]. The median score in their study was 33 which was lower than 51 reported in our study.…”

Orthopaedic, trauma surgery, and Covid-2019 pandemic: clinical panorama and future prospective in Europe

“…For each of these factors a value from 1 to 5 based is assigned on both objective measures and perceived clinical probabilities. Lower values were associated with greater outcome, reduced risk of Covid-19 transmission to the healthcare team, and/or reduced hospital resource use during the pandemic [ 103 , 104 ]. The MeNTS has been also applied with success for difficult decisions on prioritization of surgery in the orthopaedic and trauma surgeries during the pandemic [ 105 ].…”