COVID-19 Pandemic: Staged Management of Surgical Services for Gynecology and Obstetrics
Emily E. WEBER LEBRUN, MD, MS; Nash S. MOAWAD, MD, MS; E I. ROSENBERG, MD, Timothy E. MOREY, MD; Laurie Davies, MD; William O. COLLINS, MD; and John C. SMULIAN, MD, MPH
Emily E. WEBER LEBRUN, MD, MS University of Florida College of Medicine, Department of Obstetrics & Gynecology
Nash S. MOAWAD, MD, MS University of Florida College of Medicine, Department of Obstetrics & Gynecology
Eric I. ROSENBERG, MD University of Florida College of Medicine, Department of Medicine
Timothy E. MOREY, MD University of Florida College of Medicine, Department of Anesthesiology
Laurie Davies, MD University of Florida College of Medicine, Department of Anesthesiology
William O. COLLINS, MD University of Florida College of Medicine, Department of Otolaryngology
John C. SMULIAN, MD, MPH University of Florida College of Medicine, Department of Obstetrics & Gynecology
Acknowledgements: We would like to acknowledge the thoughtful contributions of Islam MD, Brian Hoh MD, Brent Carr MD, Jeffrey White MD, Laurie Davies MD and Parker Gibbs MD, all from the University of Florida College of Medicine without compensation.
Disclosures: The authors have no relevant conflicts of interest or financial disclosures.
Word Count: Abstract 168; Text 2043
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Condensation: During the COVID-19 pandemic, a staged reduction in gynecologic and obstetric surgical services is needed to protect patients and the healthcare workforce, conserve personal protective equipment, and allow redeployment of facility resources.
Short Title: Staged Surgical Postponement during COVID-19 Pandemic
ABSTRACT:
The COVID-19 pandemic has required an unprecedented global healthcare response requiring maintenance of existing hospital-based services while simultaneously preparing for high-acuity care for infected and sick individuals. Hospitals must protect patients and the diverse healthcare workforce by conserving personal protective equipment and redeployment of facility resources. While each hospital or health system must evaluate their own capabilities and surge capacity, we present principles of management of surgical services during a health emergency and provide specific guidance to help with decision-making. We review the limited evidence from past hospital and community responses to various health emergencies and focus on systematic methods for adjusting surgical services to create capacity, addressing the specific risks of COVID-19. Successful strategies for tiered reduction of surgical cases involve multi- disciplinary engagement of the entire healthcare system and use of a structured risk- assessment categorization scheme which can be applied across the institution. Our institution developed and operationalized this approach over three working days, indicating that immediate implementation is feasible in response to an unforeseen healthcare emergency.
Key Words: COVID-19, coronavirus, SARS CoV2, gynecology, obstetrics, surgery, staged management, case cancellations, emergency response, surgical subspecialties
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1 INTRODUCTION:
2 The global, national and local health care response to the novel Coronavirus
3 Disease 2019 (COVID-19) provides an opportunity to share best-practices for managing
4 surgical services during a health-related crisis. A response to any health emergency must
5 be tailored to the specific threat, be it infectious (such as COVID-19 or influenza), a
6 natural weather event, bioterrorism or an active shooter. The role of surgical services in
7 a health-related emergency is important and has potentially modifiable components
8 related to health care delivery. Variables to be considered when determining how
9 surgical services might be adjusted must factor in the anticipated impact and duration of
10 the event, the reliance on peri-operative and institutional resources, and the impact of
11 adjusting routine operations on both affected and unaffected patient populations.
12 Decisions regarding the cancellation, postponement and prioritization of surgical
13 services are frequently dictated by the specific threat, but the timing of making changes
14 can present the most difficult challenge. Importantly, the principles that guide decisions
15 are similar regardless of the emergency. In order to help institutions or clinical practices
16 that are considering changes to surgical services because of the COVID-19 pandemic, we
17 present principles of management of surgical services during a health emergency and
18 provide specific guidance to help with decision-making.
19 PLANNING CONSIDERATIONS
20 The World Health Organization (WHO) provides an all-hazards list of key actions
21 to be considered by hospitals in response to any disaster event.(1) This tool provides
22 guidance regarding establishing a command center, consistent and effective
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23 communication, prioritization of safety and security, the logistics of triage and supply
24 management in light of surge capacity while maintaining essential services and post-
25 disaster recovery planning. In 2014, the WHO hospital emergency response checklist
26 was used as an evaluation toolkit to assess the preparedness of 15 hospitals in Italy in a
27 cross-sectional study and showed that most had adequate command and control
28 response operations, but had insufficient communication systems for potential
29 disaster.(2) While there is some correlation between the level of hospital care and
30 preparedness, there was a poor level of readiness to implement strategic and logistical
31 plans. In fact, some hospitals successfully anticipated infrastructure needs such as
32 water, sanitation, and electricity, but failed to demonstrate a coordinated and strategic
33 plan for surge capacity.
34 Inpatient surge capacity is the ability to generate staffed beds in response to a
35 surge in demand for inpatient healthcare services. In times of emergent increase in
36 healthcare demand, the goal is to increase capacity between 10-20%, although the
37 target may vary based on specific circumstances.(2,3) Financial demands
38 have traditionally prompted hospitals to maintain a high inpatient census to meet
39 tighter budgets. Naturally, this limits their ability to respond to a sudden large surge in
40 demand over the typical occupancy of 90-95%.(4) This is particularly true for times of
41 high occupancy during natural surge cycles as can be seen with the influenza or
42 respiratory syncytial virus (RSV). Those large (sometime academic), nonprofit and
43 safety-net hospitals with Level I trauma centers depend on the financial security of
44 maintaining a high patient census and large surgical volumes. These sites will also be
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45 relied on for expertise in caring for non-surgical patients with critical illness resulting
46 from an emerging pathogen, in addition to the ongoing demands of high-level surgical
47 services.
48 ADJUSTMENT OF SURGICAL SERVICES
49 Despite these conflicts, one strategy to free up capacity within a hospital system
50 is through cancellation of non-essential surgical cases which most commonly occurs in
51 an unstructured and decentralized manner.(5) As seen previously, nonsystematic
52 modifications of procedural schedules as well as adjusting admission and discharges
53 were shown to reduce occupancy and demand of non-urgent hospital resources after
54 the New York attacks in 2001 and after the SARS Toronto outbreak in 2003 by 9% and
55 12% respectively.(6) In 2016, researchers reported a structured system of categorizing
56 surgical procedures based on the potential impact on inpatient surge capacity if a
57 procedure was to be cancelled or delayed.(5) Using chart review, all planned procedures
58 over a 4 week period (n=2,821) were categorized based on their impact on inpatient
59 capacity and the safety of their delay into one of four groups: (A) procedures with no
60 impact on inpatient capacity; (B) procedures that could be delayed indefinitely; (C)
61 procedures that could be delayed by one week; and (D) procedures that could not be
62 delayed. This strategy of delaying scheduled cases in categories B and C most effectively
63 (especially on Mondays) led to a reduction of inpatient occupancy by 8% (65
64 beds). While category A cases, such as outpatient procedures and same-day
65 procedures, do not impact inpatient occupancy, they do require other equipment and
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66 staffing resources, thus limiting potential surge capacity during a healthcare crisis
67 requiring intensive patient care.
68 An important element of managing surgical services in the setting of a healthcare
69 emergency is planned coordination throughout the hospital system, including the
70 various surgical departments, anesthesia, and nursing services. In the current COVID-19
71 crisis, the American College of Surgeons (ACS) issued the following recommendation:
72 “Each health system and surgeon should thoughtfully review all scheduled elective
73 procedures with a plan to minimize, postpone or cancel elective [cases] until we can be
74 confident that our health care infrastructure can support [an increase] in critical patient
75 care needs.”(7) A joint statement from leading societies in gynecologic surgery as well as
76 the US Surgeon General encouraged hospitals to consider modifying surgical scheduling
77 in areas where COVID-19 is prevalent.(8,9) Effective rescheduling of surgeries should
78 involve engagement of the entire hospital system with specific attention to the unique
79 demands of the crisis at hand. Also of importance, many surgeries are performed in
80 settings outside of hospital systems through either free-standing outpatient surgical
81 centers or in clinical offices. These entities are usually excluded from planning
82 considerations since they are often removed, both operationally and financially, from
83 the larger hospital systems. This creates a potential conflict-of-interest when making
84 decisions about surgery reductions. Communication during a healthcare emergency is
85 critical, and differences in the management of elective cases can interfere with
86 consistent messaging across an institution and to the public. Community practices and
87 non-affiliated surgical facilities should be included in this process and have similar
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88 expectations for adjusting care. In the event of widespread COVID-19 infection, all
89 resources may be severely strained and should be conserved to care for life threatening
90 infections rather than elective surgical procedures.
91 The wide spectrum of clinical manifestations seen in COVID-19 complicates
92 predictions of the impact on healthcare. Therefore, it is difficult to anticipate when the
93 epidemic will peak and introduces further difficulty in the detection of
94 cases.(10) Current data suggests that the risk for developing acute respiratory distress
95 syndrome (ARDS, 17-29%) and death (1%) are most commonly seen in the elderly (over
96 age 70) and those with underlying respiratory illness.(11) Clinically recognized infection
97 in children seems less frequent (2%), and limited data suggests that pregnant women
98 are not particularly vulnerable to contracting the illness and have similar maternal
99 complications to other populations.(12) There appears to be an increased risk for
100 preterm birth, fetal distress and cesarean delivery with infection.(11) Nevertheless, 1:1
101 obstetric and pediatric staffing and the resultant personal protective equipment (PPE)
102 needs offer additional strains on resources.
103 GYNECOLOGIC AND OBSTETRIC SURGERY
104 Preparing for COVID-19 community spread requires emergency response
105 planning as outlined by the WHO. Additional preparedness actions can be elucidated
106 from the Italian experience which provides guidance on forecasting ICU surge capacity
107 and promoting containment measures once the outbreak has begun.(13) However,
108 there is little guidance for managing scheduled, elective surgical services while awaiting
109 the onslaught of COVID-19 cases. While hospital leadership is engaged in logistical
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110 planning, the maintenance of some limited surgical services may provide a financial
111 balance to hospitals and allow physicians and staff to remain focused on providing high
112 quality care. Utilizing the principles from Soremekun et al, it is possible to develop
113 specialty-specific case categories and establish a schedule for tiered, coordinated case
114 cancellation/postponement.
115 Table 1 shows the staged reduction considerations for gynecologic and obstetric
116 surgeries used at the University of Florida to guide decision-making. Category I includes
117 elective cases of any type performed on a patient at high risk of complications
118 associated with COVID-19 infection. In the setting of COVID-19, Category I was designed
119 to identify all patients across all services whose mere presence in a densely populated
120 hospital with community transmission of COVID-19 would pose a greater risk to the
121 patient than to postpone their surgery. For example, urogynecology largely serves older
122 patients who are also at high risk of morbidity and mortality resulting from COVID-19
123 infection but whose surgical treatment can usually be delayed for patient protection.
124 Categories II and IV are similar except for the post-operative hospital-care
125 burden. Cases in Category II require overnight hospitalization or potential intensive care
126 and can be postponed if the hospital resources are over-stretched. In contrast, cases in
127 Category IV occur in an off-site or independent ambulatory care center, and therefore
128 could continue without straining hospital-based resources. (Since some health systems
129 do not maintain separate locations or surgical environments, Categories II and IV may
130 not be distinct for those centers.) While individuals in Categories II and IV may be at
131 lower risk for viral morbidity (such as most patients with benign and pediatric
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132 gynecology needs), if their surgery is non-essential and their potential exposure places
133 the community at greater risk, consideration should be given to postponement. In
134 contrast, prior to evidence of community spread of COVID-19, early completion of
135 Category IV cases will serve that low-risk population without expending significant
136 resources and reduce additional hospital burden once the crisis resolves. Thus, both the
137 specific community environment and COVID-19 risk must be considered.
138 Category III describes urgent patients (or cases) that need to be performed
139 within the next 7-14 days, but which can be scheduled strategically based on hospital
140 resources. In the setting of COVID-19, terminal cleaning of an OR, preparation of
141 adequate PPE or mobilization of staff may be prioritized to strategically delay a Category
142 III case. For example, surgical oncology cares for patients at the highest risk for
143 contracting COVID-19 and, simultaneously, for experiencing devastating outcomes with
144 a delay in cancer care. These cases best fit into Category III, prompting a case review
145 and individualized risk assessment. Finally, Category V cases are emergent and should
146 not be delayed for any reason. Emergent cases such as ovarian torsion and ectopic
147 pregnancies fall into Category V, for which a careful risk-assessment is undertaken and
148 the case performed urgently with mobilization of available resources.
149 This categorization strategy depends heavily on surgeons to fairly identify several
150 key factors about the patient and the planned surgery, to weigh the relative impacts of
151 those factors on the overall health of the patient and to seek peer review when
152 confounding factors are involved. When considering surgical patients who are
153 symptomatic or test positive for COVID-19, we suggest a multi-disciplinary team must
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154 balance the various risks and benefits to the patient as well as to the entire healthcare
155 system.
156 There are a number of considerations for triggering a staged reduction in surgical
157 services (Table 2). Nevertheless, for COVID-19, the emergence of local or regional
158 community transmission is the most important reason. Since pregnancy care (antenatal,
159 intrapartum and postpartum) is not optional, it is particularly important to conserve and
160 protect this highly specialized workforce and assigned PPE resources to safely ensure
161 the ability to provide services during the outbreak. This may mean an earlier reduction
162 of benign gynecologic surgeries than for other specialties.
163 While each hospital or healthcare system must evaluate their own capabilities
164 and surge capacity, this approach can be applied across all surgical departments
165 allowing for a consistent and measured management of resources. We have provided an
166 expanded table with additional categorized examples from other procedural specialties
167 that might be useful for guiding decisions including general surgery, pediatric surgery,
168 neurosurgery, otolaryngology, and psychiatry. (Appendix 1)
169 SUMMARY
170 Lessons learned from the widespread COVID-19 epidemic in China show a high
171 rate of infection in healthcare personnel, up to 63% in Wuhan (1080 of 1716),
172 with 14.8% cases classified as severe or critical (247 of 1668) and 5 deaths.(12,13) This
173 can quickly overwhelm resources and make it very challenging to provide adequate care
174 for ill COVID-19 patients. Minimizing all unnecessary patient contact through proactive
175 systematic postponement of elective surgical cases and all non-essential outpatient
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176 visits is key to channeling all health care resources to overcoming this COVID-19
177 pandemic.
178
179 Bibliography
180 1. World Health Organization: Regional Office for Europe. Hospital emergency
181 response checklist: An all-hazards tool for hospital administrators and emergency
182 managers. [Internet]. World Health Organization. 2011 [cited 2020 Mar 14].
183 Available from: http://www.euro.who.int/__
184 data/assets/pdf_file/0020/148214/e95978.pdf
185 2. Ingrassia PL, Mangini M, Azzaretto M, Ciaramitaro I, Costa L, Burkle FM, et al.
186 Hospital Disaster Preparedness in Italy: a preliminary study utilizing the World
187 Health Organization Hospital Emergency Response Evaluation Toolkit. Minerva
188 Anestesiol. 2016 Jun 7;82(12):1259–1266.
189 3. Kelen GD, McCarthy ML, Kraus CK, Ding R, Hsu EB, Li G, et al. Creation of surge
190 capacity by early discharge of hospitalized patients at low risk for untoward
191 events. Disaster Med Public Health Prep. 2009 Jun;3(2 Suppl):S10–6.
192 4. DeLia D, Wood E. The dwindling supply of empty beds: implications for hospital
193 surge capacity. Health Aff (Millwood). 2008 Dec;27(6):1688–1694.
194 5. Soremekun OA, Zane RD, Walls A, Allen MB, Seefeld KJ, Pallin DJ. Cancellation of
195 scheduled procedures as a mechanism to generate hospital bed surge capacity-a
196 pilot study. Prehosp Disaster Med. 2011 Jun;26(3):224–229.
11
197 6. Kanter RK, Moran JR. Hospital emergency surge capacity: an empiric New York
198 statewide study. Ann Emerg Med. 2007 Sep;50(3):314–319.
199 7. American College of Surgeons. Information for Surgeons COVID-19:
200 Recommendations for Management of Elective Surgical Procedures [Internet].
201 Information for Surgeons COVID-19: Recommendations for Management of
202 Elective Surgical Procedures. 2020 [cited 2020 Mar 12]. Available from:
203 https://www.facs.org/about-acs/covid-19/information-for-surgeons
204 8. Joint Statement on Elective Surgeries | ACOG [Internet]. [cited 2020 Mar 27].
205 Available from: https://www.acog.org/news/news-releases/2020/03/joint-
206 statement-on-elective-surgeries
207 9. U.S. Surgeon General. Hospitals & healthcare systems, PLEASE CONSIDER
208 STOPPING ELECTIVE PROCEDURES until we can #FlattenTheCurve [Internet].
209 Twitter. 2020 [cited 2020 Mar 26]. Available from:
210 https://twitter.com/Surgeon_General
211 10. Peeri NC, Shrestha N, Rahman MS, Zaki R, Tan Z, Bibi S, et al. The SARS, MERS and
212 novel coronavirus (COVID-19) epidemics, the newest and biggest global health
213 threats: what lessons have we learned? Int J Epidemiol. 2020 Feb 22;
214 11. Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus Disease
215 2019 (COVID-19) and Pregnancy: What obstetricians need to know. Am J Obstet
216 Gynecol. 2020 Feb 24;
217 12. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the
218 Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of
12
219 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA.
220 2020 Feb 24;
221 13. Grasselli G, Pesenti A, Cecconi M. Critical Care Utilization for the COVID-19
222 Outbreak in Lombardy, Italy. JAMA. 2020 Mar 13;
223
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Table 1. General guidance to assist gynecologists and obstetricians with staged cancellation or postponement of surgical cases in response to the COVID-19 pandemic. Individual case-specific characteristics may modify category assignment for a given patient.
Category: I II III IV V Trigger(s) to - Community transmission - Community transmission - Community transmission - Community transmission Never cancelled cancel or - Inpatient bed availability - Inpatient bed availability - PPE supply limited delay limited limited - PPE supply limited - Case-by-case basis with team review COVID-19 High Average Average Average All risk levels morbidity and Vulnerable Population mortality risk Urgency Level Low Low Moderate Low High (can delay up to 14 days) Impact on bed Variable by procedure Variable by procedure Variable by procedure No impact High capacity (possible inpatient) (possible inpatient) (possible inpatient) (same day surgery) (inpatient, emergency department) Examples of patient characteristics and/or surgical case types Benign For All Surgical Groups - Excision of pelvic - Excision of benign mass - Interval tubal ligation - Ectopic pregnancy Gynecology masses without high affecting health - Hysteroscopy - Ovarian torsion -- Immunocompromised suspicion of malignancy (causing ureteral - D&C - Tuboovarian − Elderly (over age 70) - Hysterectomy for obstruction) - Minor adnexal surgery abscess requiring − Respiratory disease benign disease - Missed abortion - Minor laparoscopy surgery − Other comorbidities - Major minimally- - Minor vaginal surgery - Uncontrollable invasive surgery uterine bleeding no (excision of advanced cancer endometriosis or - Incomplete abortion adhesions) Urogynecolog - Hysterectomy (with - Mass resulting in - Minor pelvic floor - Unreducible y overnight stay) urinary obstruction repairs procidentia - Major pelvic floor - Minimally-invasive resulting in acute repairs surgery urinary retention - Sacral colpopexy - Hysterectomy (same day discharge)
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Gynecologic - Hysterectomy for - Excision of malignant - Surgery for pre-invasive - Bowel obstruction Oncology complex benign disease mass disease EIN, VIN, VAIN, - Uncontrollable - Prophylactic surgery - Hysterectomy for early CIN uterine bleeding from heritable cancer risk endometrial cancer cancer - Cysts followed for long - Pelvic mass causing periods without change severe symptoms and negative serum markers (Benign Gyn or Gyn Onc) Reproductive − Abdominal N/A − Hysteroscopy, D&C - Ectopic pregnancy Endocrinology Myomectomy − Septoplasty - Ovarian torsion and Infertility − Adnexal surgery - Treatment of − Minor laparoscopy ovarian − IVF Retrievals and hyperstimulation Transfers − IUIs and Office Procedures
Obstetrics - Considered a vulnerable - Delayed postpartum − Scheduled cesarean N/A - Emergent cesarean population and should tubal ligation (separate − Scheduled labor - Emergent cesarean only have indicated anesthesia episode) induction hysterectomy procedures to preserve - Ovarian cystectomy - History indicated - Rescue cerclage maternal and fetal cerclage - Incarcerated uterus health - Amniocentesis - Ovarian torsion - Chorionic villous - Intrauterine sampling Transfusion - Tubal ligation at cesarean or with delivery
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Table 2: Selected considerations important for guiding decisions surrounding a staged reduction in surgical services during the COVID-19 pandemic.
Public Health Concerns • Extent of community transmission
Patient Concerns • Risk for mortality for nosocomial infection • Comorbidities confounding screening (e.g. tracheostomy) • Urgency of surgical indication • Health impact(s) if procedure postponed/cancelled
Healthcare System Concerns • Availability of personal protection equipment (PPE), both general surgical masks and COVID-19 resistant air-purifying masks/head coverings • Availability of blood bank resources • Availability and health of surgical teams o Surgeon o Anesthesiologist o Specialty consultative clinicians o Surgical assistance o Nursing support o Custodial and Sterile-processing staff • Room capacity o Operating suites with negative pressure capabilities o Pre-operative areas o Post-operative areas o Inpatient rooms o Emergency department
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Appendix 1. General guidance to assist surgeons and hospital leaders with staged cancellation or postponement of surgical cases in response to the COVID-19 pandemic. Individual case-specific characteristics may modify category assignment for a given patient. The surgical services available at any individual health center will vary. This table is intended as a guide and could be expanded or modified for use in any individual hospital.
Category I II III IV V : Trigger(s) to - Community - Community - Community - Community - Never cancelled cancel or transmission transmission transmission transmission delay - Inpatient bed - Inpatient bed - PPE supply limited availability limited availability limited - PPE supply limited - Case-by-case basis with team review COVID-19 High Average Average Average All risk levels morbidity and mortality risk Urgency Level Low Low Moderate Low High (can delay up to 14 days) Impact on bed Variable by procedure Variable by procedure Variable by procedure No impact High capacity (possible inpatient) (possible inpatient) (possible inpatient) (same day surgery) (inpatient, emergency department) Examples of patient characteristics and/or surgical case types General For All Surgical Groups - Excision of benign mass - Excision of malignant - Day-stay surgeries - Emergent trauma or Surgery - Joint replacement mass - Surgical Centers acute abdomen -- Immunocompromised - Cosmetic procedures - Cardiac catheterization - Procedures on patients (hemorrhage) − Elderly (over age 70) for stable angina already admitted, - Required surgical − Respiratory disease - Fixation of closed allowing for immediate intervention for infection − Other comorbidities (as orthopedic injury discharge specifically listed) - Spinal cord decompression - Transplants - Cardiac catheterization for acute myocardial infarction - Procedures on ICU patients (open
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abdomen, PEG, tracheostomy) Burn Surgery -Release of burn scar - -Release of burn scar -Laser based fractional - -Excision/Debridement, contractures in cases contractures in cases ablation of hypertrophic preparation and without impending with impending scars coverage of Burns or functional compromise functional compromise - -Scar revision and wound beds from contracture from contracture release of burn scar - Amputation contractures (when - Tracheostomy for high deemed feasible as an risk airways or to outpatient surgery) facilitate wound treatment Breast, - Lymph node dissection - Excision of benign mass - Breast abscess Melanoma - Total - Partial mastectomy - Sarcoma that has thyroidectomy/bilateral - Parathyroidectomy received radiation neck dissection - Thyroid lobectomy therapy - Mastectomy - Adrenalectomy
Colorectal - AIN/Condyloma cases -Non urgent benign - Intestinal resection for - Non urgent benign - Urgent/emergent (impacts N95 mask anorectal cases cancer, diverticulitis, anorectal cases usually intestinal surgery for supply) requiring inpatient stay inflammatory bowel treated as outpatient perforation, obstruction -Pelvic floor repair disease (excluding - Urgent/emergent (rectal prolapse, etc.) AIN/condyloma) anorectal cases: - Sacral nerve stimulator abscess; incarcerated for incontinence prolapse; necrotizing - Colonoscopy infections of the perineum Minimally - Anti-reflux procedures -Elective incisional - Repair of symptomatic - Groin hernia repair -Urgent/emergent Invasive in lung transplant hernia repair hernias - Endoscopy intestinal surgery for patients -Anti-reflux procedures - Cancer resection perforation, obstruction -Bariatric procedures - Surgical procedures for severe nutritional depletion Pancreas, - Symptomatic incisional - Chronic pancreatitis - Pancreas cancer - Biliary colic - Cancer patients Biliary hernia - Liver metastasis - Biliary pancreatitis receiving neoadjuvant - Symptomatic incisional therapy where surgical hernia timing is driven by radiation treatment 18
Plastics -Reconstruction of -Cleft palate surgery -Breast reduction -Acute traumatic existent, non-functional -Craniosynostosis -Aesthetic/cosmetic reconstruction: facial conditions: delayed surgery fractures, long-bone breast reconstruction, -Hand/upper extremity fractures and acute soft chronic wounds, facial outpatient surgery tissue reconstruction. palsy free flaps -lipomas and other -Reconstruction for outpatient skin/soft acutely created cancer tissue benign tumors defects -migraine surgery - Aggressive cutaneous cancer resections (melanoma, Merkle cell) Vascular - Severe COPD - Elective Venous Cases - <6cm AAA - New Hemodialysis Access- CLI and ALI procedures Interventions for Creation >6cm AAA or TAAA Claudication - Symptomatic Carotid - Asymptomatic Carotid - Ruptured or infected Procedures procedures (vascular surgery emergencies) - Aortic Dissections - Acute Mesenteric Ischemia Cardiac - CABG stable CADz N/A - Acute Aortic Dissection - TAVR/ Valve nonurgent - Transplants - TEVAR non urgent - Left Main Coronary - Aneurysm non urgent Artery disease/CABG - VAD - Post MI VSD, Mitral Thoracic -Surgical Lung Biopsy - Diaphragmatic plication - Lung Cancer Surgery N/A - Lung Transplant - Decortication for stable - Esophageal Cancer Surgery patients admitted to TVICU trapped lung - Mediastinal Tumor - ECMO cannulation and - Lung Transplant patients initiation awaiting at home or floor - Thymectomy on unstable - Empyema thoracoscopy myasthenic patients
Congenital - Elective heart defects -Some single ventricular -Single Ventricles that Heart Surgery -Chronic heart defects patients. are hypoxemic with -Some patients with shunt -Transplants -ASD, sinus venous ASD lesions. -VADs for sick heart with PAPVR failure patients -Infected endocarditis 19
-Elective VSD in older -Kids in acute heart patients failure -Infections requiring urgent surgery
Congenital -Transplant -Elective device closures - Single ventricle pt. cath -Routine diagnostic cath -Inpatient requiring Heart Cath (surveillance cath) -Non-critical valve -Transplant pts with without planned urgent diagnostic cath -Chronic lung disease interventions and stents concern for rejection intervention or therapeutic -Trach/vent dependent - Asymptomatic outpt. -Symptomatic patients intervention -Other comorbidities transcatheter valve requiring valve -Transplant pts with involving CV/pulm implantation intervention/ concerns for acute systems (mainly ACHD implantation, stent rejection placement or device closure Congenital -Transplant -Implantable loop -EPS/ablation of SVT -EPS/ablation of VT - Ablation for unstable Heart EP -Chronic lung disease recorder implant -Pacemaker or ICD -Pacemaker implant refractory arrhythmias -Trach/vent dependent -Diagnostic EPS only generator replacement (new) -Infected device -Other comorbidities -Device upgrade +/- -Primary prevention ICD extraction involving CV/pulm extraction (elective) implant -Secondary prevention systems (mainly ACHD ICD implant (post- arrest) Pediatric - Cystic Fibrosis - Stoma reversals - Bowel Resections (non - Inguinal Hernia repair -All emergent procedures Surgery - Respiratory illness / vent - Outpatient gastrostomy obstructive) - Orchiopexy (e.g. appendicitis, dependent tubes (with temporary - Symptomatic gallbladder - Circumcision cholecystitis, trauma, burn - Large burns (immune tube in place) disease - Umbilical hernia debridement, bowel issues) - Congenital lung lesions - Need for feeding access - Integumentary obstructions, GI bleeding) - Benign masses (especially inpatients to Surgery (skin lesions, -malignancies requiring - Outpatient facilitate discharge) nail lesions, etc.) biopsy or resection to start Cholecystectomy - Some malignancy - EGD / Colonoscopy therapy - Interval Appendectomy associated procedures - Breast masses -Empyema not responding - Neck masses (e.g.Thyroid)(central access, resections) - Neck masses to medical management - Small burns (outpatient) (superficial) -Newborn surgical - Awaiting surgery for procedures discharge (hernia, g- -ECMO tube, others) -Incarcerated hernia -esophageal/Airway foreign bodies 20
-Gonadal torsion (testicular, ovarian)
Abdominal -Elderly (over age 70) – - Excision of benign -Excision of some -Day-stay surgeries -Acute abdomen or Transplant unless need for urgent mass malignant masses -Procedures on patients surgical equivalent Surgery dialysis access -Living Donor Kidney already admitted, -Required surgical -Pancreas transplants Transplants (being allowing for immediate intervention for delayed until at least discharge infection April 28, 2020 as of -Liver Transplants 3/17/2020; will then be MELD over 25 or ill reassessed) -Detailed acceptance criteria for deceased donor kidney transplants created based on both recipient and donor graft risk criteria -Excision of some malignant masses Neurosurgery - any open surgical or - Open surgical elective - Endovascular elective - diagnostic cerebral - Ruptured aneurysm, endovascular elective aneurysm, open surgical aneurysm, endovascular angiograms ruptured AVM, acute Vascular aneurysm, any open elective AVM, open elective AVM, stroke, ICH surgical or endovascular surgical carotid in patient endovascular elective elective AVM of any age carotid in patient of any age Neurosurgery - Elective degenerative - Resection of benign - Spinal condition with a - 1 or 2 level lumbar - Spinal cord/ nerve spine surgery without spinal mass, e.g. stable motor deficit > 72 decompression compression or spinal Spine motor deficit, or stable meningioma, hours - 1 level anterior instability with < 72 motor deficit > 3 schwannoma without Any spinal condition that is cervical surgery or 1-2 hours motor deficit, or months. motor deficit or stable not emergent but requires level posterior cervical progressive motor motor deficit > 3 inpatient management untildecompression deficit within 72 hours months definitively treated (e.g. Spinal instability that unstable thoracic fracture - Single level ACDF, - Spine fracture, Spine can be managed on bed rest until surgery) microdiscectomy, single pathology with an indefinitely with a brace Malignant primary or level laminectomy acute severe neurologic secondary spinal tumor deficit (ie tumor, - Elective spinal abscess/osteo, cauda procedure requiring equina) 21
multilevel spinal - Progressive Cervical or instrumentation ( thoracic myelopathy, Spine cervical, thoracic or tumor without deficit but lumbar) cord compression
Neurosurgery - Benign brain tumors, - MVD cases where patients - Outpatient - Intracranial bleeding, Stereotactic/ - Benign, minimally elective cervical/lumbar are in a lot of pain, radiosurgery and RFL symptomatic large Radiosurgery/ symptomatic tumor stenosis cases symptomatic benign cases brain tumors, Brain Tumors, posterior fossa lesions symptomatic spinal Trigeminal - Benign minimally - Malignant brain tumor cord lesions, trauma Neuralgia symptomatic tumor of any - Benign tumor of any age of any age age with moderate neurologic - Hospitalized benign symptoms brain tumor patient with significant neurologic symptoms or hospitalized malignant brain tumor Pediatric - Respiratory illness / vent - Chiari decompression - Cranioplasty s/p - Scalp dermoid - Shunt Neurosurgery dependent (most) decompressive craniectomy- Cranial spring removal placement/revision - Cranioplasty for skull - Craniosynostosis (most) - Muscle/nerve biopsy - Spinal dehiscence or contour - Spinal cord detethering - Vagus nerve instability/trauma - Craniotomy for epilepsy (most) stimulator battery - Endoscopic focus, non-tumor - Cranial / spinal tumor replacement hydrocephalus surgery - Vagus nerve stimulator biopsies / resections (most) - Evacuation of new implant - Discectomy / laminectomy intracranial / - Baclofen pump new without acute neuro deficit intraspinal hematoma implant - Pseudomeningocele repair or empyema - Dorsal rhizotomy (most) - Myelomeningocele - Stereo EEG - Moyamoya bypass closure - Scoliosis or other spinal - Baclofen pump - Congenital deformity repair (1-3 replacement encephalocele repair month delay) - CSF leak repair - Discectomy / laminectomy w/ acute neuro deficit
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- Decompressive craniectomy - Repair of open or depressed skull fracture - Other urgent or emergent cases as dictated by patient status Neurosurgery - Any elective epilepsy or - RNS for epilepsy, - VP shunt for - Sural nerve biopsy - Transphenoidal pituitary case in patient 70 transphenoidal surgery forpseudotumor surgery for pituitary Epilepsy years or older or with pituitary tumor, stereo EEGpituitary tumor with - VNS placement and apoplexy Surgery, pulmonary disease for epilepsy, anterior visual field defect VNS generator change Pituitary temporal lobectomy for Tumors epilepsy
Neurosurgery Any elective DBS or batteryElective DBS surgery in Battery change Infected DBS or infected change procedure in patientpatients <70 years old procedures in patients battery DBS 70 years or older, <70 years old immunocompromised, or with respiratory disease
Otolaryngolog - Immunocompromised - Most tonsil/adenoid -Malignancy of upper Cases occurred at an - Emergent airway y - Elderly (over age 70) removals aerodigestive tract or Ambulatory Surgical - Neck abscesses - Chronic respiratory - Benign thyroid & parotid salivary glands Center - Orbital or intracranial -CSF leaks disease masses complications of otitis -Sinonasal tumors - Cystic fibrosis - Tympanoplasties & media or sinusitis - Elective aerosol- -Facial trauma mastoidectomies -Laryngotracheal stenosis, Invasive fungal sinusitis generating procedures, - Cochlear implants esp. if not tracheotomized such as endoscopy, - Chronic inflammatory **These cases could wait a bronchoscopy endoscopic sinus surgery short duration, but not > 3-4 weeks. - Tracheotomy dependent Septorhinoplasty
Psychiatry - Immunocompromised -Maintenance ECT for -Post ECT taper -High acuity in mid-ECT -Catatonia with severe - Elderly (over age 70) prevention of relapse -Non-suicidal in ECT series malnourishment ECT - Respiratory disease treatment series 23
- Cardiac disease -Suicidal inpatients in mid- Other comorbidity ECT series
Trauma - - Malunion - Some fractures - Minor hardware - Acute fractures Orthopedics - Some nonunion with removal - Infection intact hardware - Manipulation under - Polytrauma - Post-traumatic anesthesia fusion/arthroplasty - Some fractures
Foot and - - Most elective - Some elective partial foot - Most elective sports, - Acute or acute on Ankle - below knee amputation amputation arthritis, outpatient - chronic infections - Most Charcot - Some elective below trauma, reconstructive - Polytrauma with reconstruction knee amputation foot and ankle surgery foot fracture as - Ankle replacements or - All digit amputations main orthopedic injury similar reconstruction Orthopedic - Elective degenerative - Resection of benign - Spinal condition with a - 1 or 2 level lumbar - Spinal cord/nerve Spine spine surgery without spinal mass without stable motor deficit > 72 decompression or compression or spinal motor deficit, or stable motor deficit or stable hours microdiscectomy instability with < 72 motor deficit > 3 motor deficit > 3 - Malignant primary or - 1 level anterior cervical hours motor deficit, or months. months secondary spinal tumor surgery progressive motor - Spinal instability that - Any spinal condition that - 1-2 level posterior deficit within 72 hours can be managed is not emergent but cervical decompression indefinitely with a requires inpatient brace. management until definitively treated (e.g. unstable thoracic fracture) Orthopedic - - Benign bone - Malignant bone or - Rare - Acute fractures Oncology - Benign soft tissue - Soft tissue - Benign soft tissue or - Infection - Hardware removal bone - Pathologic fractures - Hardware revision - Malignant tumors with window for care (eg RT, chemo)
Pediatric - - Elective spine deformity - Some fractures can be - Elective LE and foot - SCFE from ED Orthopedics - Hip/LE surgery for CP, delayed 7-10 days deformity surgery - Fracture fixation or neuromuscular (ambulatory surgery casting - LE osteotomies only) 24
- Clubfoot revisions - Arthroscopy/peds - Septic sports arthritis/osteomyelitis/ - Clubfoot tenotomy abcess - Spine trauma requiring fixation Orthopedic - Knee - Should be done within 7- - Elective LE and foot - Irreducible Sports Med - Arthroscopic 14 days: deformity surgery dislocations/unstable menisectomy, - Acute shoulder (ambulatory surgery dislocations debridement, instability only) - Native or prosthetic microfracture, plica - Patella instability with - Arthroscopy/peds - Septic joint excision osteochondral fragment sports - Infection - ACL reconstruction - Acute - Clubfoot tenotomy - Native or surgical site - Shoulder displaced/unstable - Open fracture - Arthroscopic chondral fragment - ACL with bucket handle debridement, - Closed fracture fixation meniscal tear degenerative rotator - Subacute/chronic - Displaced bucket cuff repair, biceps periprosthetic joint handle meniscal tear tenodesis/tenotomy, infection without - Periprosthetic fracture slap repair, subacromial systemic symptoms ie fixation decompression, distal sepsis - Acute periprosthetic clavicle excision - Acute rotator cuff tear joint infection - Hip - Surgery that would - Subacute/chronic - arthroscopic hip result in loss of athletic periprosthetic joint surgery season if not performed infection with systemic - Elbow Major tendon/ligament symptoms ie sepsis - arthroscopic and open tear - Fractures with elbow surgery - Pectoralis neurovascular (excluding - Biceps compromise fracture/dislocation) - Achilles - Locked elbow or knee - Quad/patella - Current matched fresh - Hamstring allografts - Triceps - Collateral ligament repair - ACL repair Arthroplasty - SNF bound - Elective inpatient - Same as Level II except - Outpatient healthy Total - Fractures, acute - Primary and revision for severe limitation, joint arthroplasty prosthetic joint pain or immobility infection 25
- Dislocations of a joint - Other emergent, urgent Urology - Reconstructive surgery -PCNL for asymptomatic -excision of malignant mass -Inguinal orchiectomy -Testicular torsion for transplant clearance stone without tubes (prostate, kidney, bladder, -TURBT -Urinary tract infections -pelvic floor repairs testis, and penis) -Ureteroscopy for associated with -fistula case - Excision of benign mass asymptomatic stone obstruction -benign urinary diversion affecting health without tubes -acute urinary tract -bladder diverticulum -PCNL for symptomatic -Ureteral stent change obstruction associated -outlet reduction stones or drainage tubes in -minor pelvic floor with decline in renal procedure place repairs function - Penile prosthesis -Ureteroscopy for -anti-incontinence -Priapism - AUS symptomatic stones or procedures -Fournier’s gangrene - Penile plication drainage tubes in place -sacral -cystoscopy with clot - hidden penis repair - Pyeloplasty neuromodulation evacuation - TURP/PVP -Urethroplasty -Cysto/RUG/SPT - Explant infected -excision of benign adrenal- Ileal ureter -ProAct placement prosthetic device tumor - Ureterolysis -Male sling placement -Pediatric malignancy not -bladder and bowel - Pediatric benign -DVIU/urethral dilation testis reconstruction: bladder nephrectomy -Excision/ablation augment, bladder condyloma catheterizable channel, -UroLift cecal catheterizable -penile abnormality channel, ureteral reimplant surgery (circumcusion, penile adhesion, hypospadias) -inguinal hernia -undescended testis Pain Medicine - Minimally invasive Hospitalized Patients: pain procedures, Percutaneous pain implants and interventions/minimally percutaneous invasive pain interventions procedures/implants to Elderly (over 75) facility hospital discharge. Steroid injections for Outpatient: patients with comorbiditiesEmergency/Complications (post pulmonary/cardiac (e.g. infection) of implant transplant, COPD with O2
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dependency, uncontrolled diabetes)
Interventional Visceral Visceral Visceral Visceral Visceral Radiology - Varicose veins - Embo: fibroid - Transjugular liver biopsy - Embo: gonadal vein, - PTHD (high acuity) - Hydrocele sclerotherapy - PTHD (low acuity) liver – tumor - PCN: new (high acuity) - TIPS revision: ascites - PCN: new (low acuity) (TAE/TARE) - Embo – any - Vertebral augmentation - TIPS placement: ascites - Dialysis procedures hemorrhage - Embo: gonadal vein (possibly > 14 days) - Varicose veins - Thrombolysis - Nerve injections - Percutaneous ablation - Hydrocele - TIPS placement: hx of - Embo: fibroid (possibly > 14 days) sclerotherapy bleed - IVC filter removal - Embo: pulm AVM - IVC filter Body - CVL/port removal (possibly > 14 days) placement/removal - Abdominal/pelvic (completion of therapy) - TIPS revision: bleeding - Cholangiogram abscess drainage - Feeding tube exchange Body - Feeding tube - Empyema (routine) - Native kidney biopsy placement/change Peds Peds - Lung mass biopsy - Tunneled ascites - Intussusception - VCUGs - Abdominal mass high catheter reduction - Renograms risk biopsy - Catheter/CVL exchange - Barium study for - Barium GI series for Neuro/Spine or removal (any) malrotation chronic conditions - Multi-level blood patch - Port/tunneled CVL - MSK - Multi-staged placement - - Imaging guided soft sclerotherapy - Vertebral augmentation, tissue (trigger point) nerve injections injection - TIPS revision: ascites Neuro/Spine Body - Sclerotherapy and Botox - Breast mass biopsy injections - Thyroid FNA - Lymph node biopsy - Paracentesis/thora - Seroma/superficial abscess drainage
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- Low risk abdominal mass or soft tissue biopsy Neuro/Spine - LPs/Myelograms - FNA/biopsies of head, neck or spine - Sclerotherapy and botox injections MSK - Arthrocentesis - Imaging guided biopsy - Imaging guided soft tissue (trigger point) injection Ophthalmolog -Cataracts that impact legal -Cataracts >12 year old -Ruptured Globe y driving standards -Blepharoplasty -Endophthalmitis -Conjunctival or corneal -Chalazion -Bilateral vitreous neoplasm -Ectropion/Entropion hemorrhage -Pediatric cataracts repair -Emergency transplant -Advanced TRD in -Nasal lacrimal duct -Perforated ulcer monocular patient probing -Eyelid malignancy -Macular hole excision/repair -PPV/ERM peel -Vitreous biopsy/FNA of -Strabismus >10 yo choroidal mass -Mild/Moderate glaucoma -Rhegmatogenous RD with >135 degrees of -Advanced or neovascular binocular field glaucoma -PTK/Lasik/PRK -Hyphema with high IOP -Routine transplants -ROP -Pterygium surgery -Phacomorphic angle closure -Intraocular foreign body -intraocular tumor
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